9
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r
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.
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o
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r
c
e
:
H
o
m
e
O
Y
c
e
.
0
20000
40000
60000
80000
100000
120000
140000
160000
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
N
u
m
b
e
r
o
f
s
e
i
z
u
r
e
s
Cannabis
All drugs seizures
Fig. 2.1 Number of cannabis seizures compared with total number of drug seizures, UK 198999.
(Source: Home Office.)
46 Drug dependence in the UK and elsewhere
peak in 1996 of 5 795 000 doses, when some very large individual seizures were
made. The number of seizures involving LSDin 1998 was 609, a drop of 240 (28%)
on the previous year and the lowest Wgure since 1988. The availability, or popular-
ity, of LSD appears subject to considerable Xuctuations. Methadone seizures have
increased signiWcantly since 1992, when quantities were negligible, to 1550 in
1998, representing 82.5 kg.
2. In 1992 there were 3000 seizures involving class C drugs, mainly ben-
zodiazepines, milder stimulants, less potent analgesics and anabolic steroids. Of
these, 2840 were for benzodiazepines, including 870 for temazepam. From
1 September 1996, anabolic steroids became controlled under the Misuse of Drugs
Act 1971 (ModiWcation) Order 1996 and the Misuse of Drugs (Amendment)
Regulations 1996. There were 171 seizures of this drug in 1998, an 11%increase on
the previous year.
Persons dealt with for drug offences
The number of persons dealt with for drug oVences is yet another indicator of the
prevalence of illicit drug misuse, although the Wgures need careful analysis and
interpretation. In summary, the number of drug oVenders has continued to rise,
and the total number reported to the Home OYce in 1998 was 153 156, 13% more
than in 1997. This number has increased year on year since 1988, but fell in 1999.
Unlawful possession remains the most common oVence (Fig. 2.2). The majority of
oVenders are found in possession of cannabis but there has been a steep rise in
oVences related to heroin and cocaine (Fig. 2.3).
36
0
20000
40000
60000
80000
100000
120000
140000
1989 1991 1993 1995 1997 1999
N
u
m
b
e
r
o
f
O
f
f
e
n
d
e
r
s
Possession
Trafficking
Other
Year
Fig. 2.2 Drug offenders by type of offence, UK 198999. (Source: Home Office.)
0
2000
4000
6000
8000
10000
12000
14000
1989 1991 1993 1995 1997 1999
Year
N
u
m
b
e
r
o
f
O
f
f
e
n
d
e
r
s
Cocaine
Methadone
Heroin
LSD
MDMA
Fig. 2.3 Drug offenders by type of drug, excluding cannabis, UK 198999. (Source: Home Office.)
47 Sources of epidemiological information in the UK
Drug-related crime
A topic of continuing interest and concern is the causal relationship between
crime and substance misuse how much crime is due to substance misusers
oVending merely to support their drug habit? Drug-related crime includes
48 Drug dependence in the UK and elsewhere
acquisitive crime (e.g. theft, shop lifting, fraud and burglary), drug-dealing and
prostitution. The relationship is important because such facts are often used,
simplistically, as a reason to decriminalize illicit drug use. The complexity of this
issue is demonstrated by the Wnding that most crack cocaine addicts have long-
standing criminal records before using the drug; however, those who do not often
turn to acquisitive crime to fund their drug misuse.
37
One interesting approach is to test the urine of all arrestees not just drug
oVenders for the presence of drugs. One such study carried out in 1997 found
that 61% had recently taken at least one illegal substance and, 2 years later, this
Wgure had increased to 69%.
38,39
Nearly half of those testing positive in 1997
believed that their drug use was associated with their criminal behaviour, particu-
larly the need to steal for money to buy drugs. Relatively high proportions of
arrestees had used cocaine or opiates (18% and 10% respectively). Property
oVenders were more likely to be drug-takers than oVenders against the person,
alcohol/drug oVenders or disorderly oVenders, and a comparatively high propor-
tion of property oVenders in 1997 tested positive for opiates (23%) or cocaine
(14%) compared with other oVender groups. Almost half the shoplifters tested
positive for opiates and 3 in 10 for cocaine.
Prescription audit
Another way of investigating patterns of drug use is to assess drug distribution by
means of prescriptions.
40
This can provide information on individual drugs or
drug classes prescribed either for the total population or for selected populations.
It also, of course, allows trends and patterns of prescribing practices to be studied.
Thus it can be seen from Table 2.2 and Fig. 2.4 that the total number of
prescriptions issued by GPs increased steadily over the period 19912000 and that
the number of prescriptions for drugs that act on the nervous system, after
dipping in the mid-1980s, has been increasing since 1991. Within the overall total,
there has been a gradual, albeit Xuctuating, decline in the number of prescriptions
for hypnotics while the number of prescriptions for anxiolytics has remained
steady. Perhaps the most striking feature however is the steady increase, over the
last 10 years, in the number of prescriptions for opioid analgesics; in 2000, for
example, there were 6.8 million prescriptions for these drugs, compared with 3
million in 1991. These drugs are a frequent substance of misuse, and rising
prescription Wgures, such as those shown in Table 2.2, can act as an early warning
system if abuse is becoming widespread. The increased prescription of antide-
pressants over this time period may be a reXection of the introduction of a large
number of new drugs, such as the Selective Serotonin Re-uptake Inhibitors
(SSRIs) which have fewer and more tolerable side eVects than earlier drugs.
Of course it is possible to analyse prescription data in more detail even by
T
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5
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5
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5
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a
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s
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t
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s
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.
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%
A
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s
4
.
8
5
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.
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%
D
r
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%
D
a
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a
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s
b
a
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d
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.
S
S
R
I
,
s
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l
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t
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h
i
b
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t
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r
.
S
o
u
r
c
e
:
D
e
p
a
r
t
m
e
n
t
o
f
H
e
a
l
t
h
,
S
t
a
t
i
s
t
i
c
s
D
i
v
i
s
i
o
n
1
E
,
P
r
e
s
c
r
i
p
t
i
o
n
C
o
s
t
A
n
a
l
y
s
i
s
S
y
s
t
e
m
.
0
2
4
6
8
10
12
14
1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
M
i
l
l
i
o
n
s
o
f
p
r
e
s
c
r
i
p
t
i
o
n
s
Hypnotics
Antipsychotics
Selective Serotonin
Re-Uptake Inhibitors
Other Antidepressants
Opioid Analgesics
Drugs Used in
Substance Dependence
Fig. 2.4 Number of prescriptions for certain therapeutic subgroups acting on the nervous system,
UK 199199. (Source: Department of Health.)
50 Drug dependence in the UK and elsewhere
individual drugs. This shows for example that within the large number of pre-
scriptions for benzodiazepines, there have been more prescriptions for shorter-
acting drugs such as temazepam and lorazepam, which have become popular
because, when taken as hypnotics, they have less hang-over eVect and, when
taken through the day as anxiolytics, there is much less drug accumulation in the
body. However, it now appears that dependence on these drugs is more severe and
that withdrawal is correspondingly more diYcult fromthese shorter-acting drugs.
Although the information obtained from prescription audit is fascinating, great
care needs to be taken in its interpretation, because the method has obvious
limitations. For example, a proportion of people who receive prescriptions do not
get them dispensed (and are therefore not included in an audit of retail pharma-
cists) and a proportion of people who have their prescriptions dispensed do not
take (all of ) their drugs. In other words, it must not be forgotten that the sampling
unit is a prescription and not a patient. Furthermore, changes in prescribing may
be misrepresented; for example, changing from the practice of giving long-term
prescriptions for large amounts of a drug to giving short-term prescriptions for
small amounts would appear in the statistics as an increase in the total number of
prescriptions, even if the amount prescribed is the same or less.
Index of Addicts
Historically, the main source of epidemiological information about addiction in
the UK was the Home OYce Index of Addicts, but this was closed in 1997. Before
51 Sources of epidemiological information in the UK
1968, it was primarily based on a system of inspecting the books of dispensing
pharmacists and reports from the police. Voluntary notiWcation by medical
practitioners also contributed to this knowledge base. From 1968 to May 1997,
however, doctors had a statutory duty to notify the Home OYce of any patient
whom they considered to be dependent on certain controlled drugs (cocaine and,
from1973, a number of opiate drugs). The index of addicts was derived fromthese
notiWcations and annual statistics were published giving the total number of
notiWed addicts at the end of each year, their sex and age, the number of new (i.e.
notiWed for the Wrst time) and re-notiWed addicts, the drugs reported to be used at
notiWcation and so on.
However, as many addicts obtain drugs illicitly and are intent on concealment
from any authority, the oYcial statistics could only represent a proportion, and
probably a changing proportion, of the total number who were actually addicted.
Furthermore, at any time there were many people misusing the same drugs who
were not (yet) addicted to them. A further disadvantage of the Index was that
notiWcation was not required for a large number of controlled drugs, such as
amphetamines and barbiturates, which were and are misused and can cause
dependence, and, of course, doctors did not always fulWl their statutory obligation
to notify. Thus, although the primary function of the Index to reduce the
possibility of an individual receiving certain drugs from more than one doctor
simultaneously was largely achieved, the data it provided were of limited value,
because those who were notiWed were probably only a small proportion of regular
users. Nevertheless, even this quality of data was generally considered useful for
picking up trends and for illustrating general patterns within a restricted group of
drug users.
Number of addicts
The Home OYce Index was closed on 30 April 1997 and this account can therefore
only extend to that date. Up to and including 1996, it showed a steady, almost
relentless increase in the number of notiWed addicts since 1987, with an increase of
17% between 1995 and 1996. Thus the total number of addicts notiWed to the
Home OYce increased from14 785 at the end of 1989 to 27 976 by the end of 1993
and 43 372 by the end of 1996, a total increase of 193%. Within this huge increase,
in 1996 there were 18 281 new notiWcations, the highest number of new addicts
ever recorded in a single year, and 24% more than in the previous year (Fig. 2.5).
Altogether, new notiWcations accounted for 42% of the total.
41
It has been suggested that some of this increase may have been the result of
eVorts to attract more addicts into treatment because of fear of AIDS. There may
also have been a greater awareness of notiWcation procedures and obligations as a
result of the establishment of Regional Substance Misuse Databases (see below) by
0
2000
4000
6000
8000
10000
12000
14000
16000
1
9
8
6
1
9
8
7
1
9
8
8
1
9
8
9
1
9
9
0
1
9
9
1
1
9
9
2
1
9
9
3
1
9
9
4
1
9
9
5
1
9
9
6
Year of notification
N
u
m
b
e
r
o
f
n
o
t
i
f
i
c
a
t
i
o
n
s
Males
Females
Fig. 2.5 Newdrug addicts notified to the Home Office, UK 198696. (Source: Home Office.)
52 Drug dependence in the UK and elsewhere
Health Authorities and also because doctors were sent reminders about the
requirement to re-notify addicts in their care.
Age and sex (Table 2.3, Fig. 2.6)
The age of new addicts remained relatively stable from 1986 to 1996, with an
average age of 2627 years. However, the number in the under-21 years age group
increased after 1989 and very sharply, by 35%, between 1995 and 1996. In 1996,
74%of new addicts were under the age of 30 years and 20% were less than 21 years
old. The average age of all addicts (not just new addicts) has fallen steadily since
1992, after having gradually risen since the mid-1980s.
Although the number of new female addicts increased over the years, they
formed a smaller proportion of the total than previously. In 1996, for example,
22% of new addicts were female, compared with 28% in 1990. It can be seen from
Table 2.3 and Fig. 2.5 that the majority of new addicts are men aged between 21
and 34 years of age.
Drugs of addiction (Table 2.4, Figs. 2.7, 2.8)
The common drugs to which addiction was reported in the Index were, in order of
frequency, heroin, methadone, cocaine, morphine and dipipanone. A Wfth of
notiWed addicts were reported to be polydrug addicts.
Heroin was the most common drug of addiction for new addicts in the 1980s,
with the proportion increasing from 72% in 1980 to 93% in 1985, perhaps
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.
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1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Year
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A
v
e
r
a
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a
g
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y
e
a
r
s
)
Percentage of new addicts
under 21 years
Average age of new addicts
Fig. 2.6 Average age of newly notified addicts and percentage under 21 years of age, UK 198696.
54 Drug dependence in the UK and elsewhere
reXecting ease of availability at that time. In 1996, some 15 271 new heroin addicts
were notiWed, an increase of 32% on new notiWcations in 1995. A record number
(4724) of people were reported as newly dependent on methadone in 1996. This
was an increase of 6% on the previous year a slower rate of increase than in
previous years. About 13 900 re-notiWed addicts were reported to be dependent on
methadone in 1996, 7% more than in 1995. These increases probably reXect the
fact that more new addicts are being treated with methadone.
The number of new cocaine addicts fell in 1996 to 1714, reversing the upward
trend of previous years. Nevertheless, despite very large seizures of cocaine, its
misuse has, so far, not created a signiWcant demand for medical treatment.
The number notiWed as addicted to dipipanone fell slightly in 1996, from215 to
194, continuing the downward trend of recent years. The total is now substantially
less than in the early 1980s, suggesting that the stricter controls placed on its
prescription have been successful in controlling availability.
Among re-notiWed addicts, heroin and methadone remained the most common
T
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0
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Year of notification
N
u
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b
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r
o
f
n
o
t
i
f
i
c
a
t
i
o
n
s
Cocaine
Methadone
Heroin
Fig. 2.7 Notification to the Home Office by drug of notification, UK 199296.
56 Drug dependence in the UK and elsewhere
drugs of addiction in 1996, with 15 302 addicted to heroin and 13 893 addicted to
methadone, 85% more than in 1992. As with new addicts, the increase in the
proportion addicted to methadone is substantial: 55% in 1993. Altogether, notiW-
able drugs were prescribed to 9386 new addicts and 18 940 re-notiWed addicts at
their Wrst notiWcation in 1996, with 99% being prescribed methadone, either alone
or in combination with another drug.
Injecting status
Because of concernabout the spread of HIV/AIDS, drug abusers injecting status is
of the greatest importance (Table 2.5). In 1996, just over half (51%) of all addicts
whose injecting status was known were injecting their drugs and a higher propor-
tion of re-notiWed addicts were injecting than new addicts. Despite the stability in
the proportion of injectors, the number of addicts injecting increased to 19 011 in
1996. Of these, 2000 were aged under 21 years and must have started injecting after
information about HIV/AIDS became widely available.
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Year of notification
N
u
m
b
e
r
o
f
n
e
w
a
d
d
i
c
t
s
r
e
p
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r
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d
a
d
d
i
c
t
e
d
t
o
d
r
u
g
s
Cocaine
Methadone
Heroin
Other
Fig. 2.8 Newaddicts and drugs of addiction, UK 198696.
Table 2.5. All drug addicts notified to the Home Office by latest injecting status and sex, UK
1996
Number and percentage injecting
a
New addicts Re-notiWed addicts Total addicts
No. % No. % No. %
Males 6259 48 8728 55 14 987 52
Females 1616 44 2408 47 4024 46
All persons 7875 47 11 136 53 19 011 51
a
Percentages based on number of addicts for whom injecting status is known.
Source: Home OYce.
57 Sources of epidemiological information in the UK
Regional Drug Misuse Databases (RDMDs)
Until the mid-1990s, the only national Wgures available relating to the nature and
extent of drug use were contained within the Home OYces Index of Addicts. The
inadequacies of this system as an epidemiological tool have been outlined above
and it has beenrecognized that more comprehensive information on a wider range
of substance misuse was essential for eVective service development and policy
making at both local and national levels. In 1989 the Department of Health
therefore required all Regional Health Authorities to establish databases to moni-
58 Drug dependence in the UK and elsewhere
tor trends in drug abuse and the use of drug abuse services, and nationally collated
information (October 1992 to September 1999) is now available (for England).
Separate databases were established for other countries in the UK. However, this
system also has its drawbacks: although supposedly anonymized, data were orig-
inally required to be attributable; i.e. the drug user must be identiWed by initials,
date of birth and postcode to enable data matching and the removal of duplicate
client episodes. Apart from the ethical concerns raised by this practice (privacy,
civil liberties), it is highly probable that some drug users and/or reporting drug
agencies refused to provide attributable data, thereby compromising the epi-
demiological accuracy of the RDMDs. Because of these issues, the requirement for
attributable data has now been dropped. A further limit to the comprehensiveness
of the RDMDs arises because the Department of Health does not include data
from certain agencies such as telephone helplines and prisons, and also excludes
data where the primary substance of abuse is alcohol. Finally, it is worth noting
that this method of recording information is a mixture of incident-reporting and
case-reporting, with a potential lack of clarity in its results.
The South-West Thames Substance Use Database at the Centre for Addiction
Studies (St Georges Medical School) includes information on educational back-
ground, employment and other demographic variables as well as the subjects
alcohol use. In addition to being more comprehensive than other databases, it
maintains full conWdentiality because all data is nonattributable; at the same time
procedures are in place to prevent duplicate reporting. A similar, Europe-wide
database has been developed by the Centre and this is used by the European
Collaborating Centres on Addiction Studies (Appendices 2 and 3).
The databases collect information on all forms of drug misuse (not just
notiWable drugs) and from a wide variety of sources. For example, of the reports
made to the Drug Misuse Databases (DMDs) for the 6 months ending 31 March
2000, 47% have come from statutory Community Drug Teams, with non-
statutory, nonresidential agencies accounting for 31%, GPs for 5% and out-
patient DDTUs for 6%. In many respects, although they cover a much wider range
of drugs, RDMD Wgures broadly conWrm the picture produced by analysis of the
Home OYce Index, that most drug users presenting to services are men in their
twenties and early thirties. In total, 74% of individuals reported to the RDMDs
were using opiate drugs as their main drug (heroin 63% and methadone 9%) and
59% of those using heroin were known to be injecting it.
42
Tables 2.6 and 2.7 illustrate the type of information that can be gathered about
the sex and age of substance misusers, their injecting status and the substances of
misuse.
Table 2.6. Age and gender of users starting agency episodes in 6 months ending
30 September 2000, UK
Age group (years) Male Female All persons
:15 255 114 369
1519 3319 1664 4983
2024 7229 2847 10 076
2529 7380 2540 9920
3034 5583 1768 7351
3539 2930 990 3920
4044 1276 404 1680
4549 617 205 822
5054 259 105 364
5559 73 38 111
6064 16 15 31
964 14 17 31
All ages 28 951 10 707 39 658
59 Sources of epidemiological information in the UK
Mortality studies
Mortality studies by deWnition focus on the most serious forms of drug abuse
those fromwhich the patient has died. Causes of death are numerous, they include
overdose (suicidal, accidental or homicidal), side eVects of drugs, complications
of nonsterile self-injection and functional impairment that increases the risk of
serious accident. Because there are so many possible causes of death and because
many are not exclusively due to drug abuse, those that are, may be very diYcult to
identify among a large number of similar deaths that have nothing to do with
drugs.
17,43,44
However, the problem of mortality due to drug abuse can be tackled in many
diVerent ways:
Analysis of a series of forensically examined cases;
Analysis of national cause of death statistics;
Cause of death surveys;
Epidemiological studies on the mortality of drug consumers;
Police records (drug-related deaths, road traYc deaths involving drug misuse,
other criminal oVences involving drug- or alcohol-related fatalities);
Hospital records.
Clear diVerences exist in the indications, objectives, expense and amount of
information obtained by these diVerent methods. In most industrialized coun-
tries, cause of death statistics are the main source of data about drug overdose
deaths and are often used for international comparisons. They are valuable
Table 2.7. All drugs of misuse by category and whether injecting the drugs, for users
starting agency episodes in 6 months ending 30 September 2000, UK
Type of drug
Percentage of users
of each drug as
percentage of total
number of users
Percentage injecting
where injecting status
was known Number of users
Heroin 70 58 27 736
Methadone 20 7 7747
Other opiates 9 8 3405
Barbiturates 0 4 35
Benzodiazepines 21 2 8299
Amphetamines 8 36 3206
Cocaine 18 12 7224
Hallucinogens 1 3 379
Cannabis 27 10 861
Solvents 1 305
Alcohol 12 4730
Antidepressants 2 672
Other drugs 8 10 3281
Drug free/ no drug
coded
0 15
Note: The percentages sum to more than 100% because individuals use drugs from more than
one category.
Source: Department of Health.
60 Drug dependence in the UK and elsewhere
because they are representative but they are always out of date because of delay in
publication. In addition, as they are not substance speciWc, they cannot provide
any evidence of newtrends of drug abuse. This can be remedied to a certain degree
by forensic toxicological analysis which can give an early indication of any increase
in the number of deaths due to a speciWc drug. In England and Wales, for example,
coroners courts have proved to be a useful source of information about addict
deaths. Since the coroner must be informed of any death arising from the use of
drugs, whether occurring during treatment or as a result of mishap, abuse or
addiction, a survey of coroners courts records provides accurate information on
the number of addicts who die in a given period and whose death is in any way
related to drug-taking.
45
The following exemplify some of the approaches to studying drug-related
mortality utilized in the UK.
Table 2.8. Deaths with underlying cause described as drug dependence or nondependent abuse of
drugs, by type of drug, UK, 198595
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Morphine type
a
62 70 65 64 77 91 97 155 65 144 203
Methadone 74 114 116
Cocaine 0 2 1 2 2 3 0 0 3 6 3
Cannabis 1 2 0 0 1 0 0 0 0 1 0
Hallucinogens 0 0 1 0 0 0 1 2 0 0 0
Amphetamine type
b
3 2 1 0 2 2 5 7 4 4 13
MDMA (Ecstasy) 2 10 6
Barbiturate type 7 14 10 7 15 7 16 6 13 35 43
Volatile substances 54 46 76 89 84 112 87 68 46 39 43
Morphine with other 4 7 12 10 14 15 18 29 21 17 30
Combinations excluding
morphine
2 0 1 2 3 1 4 3 1 4 4
UnspeciWed drug dependence 22 21 24 19 27 24 31 26 45 48 53
Antidepressants 0 3 8 4 3 4 2 4 2 2 3
Other; mixed, unspeciWed,
nondependent
35 28 29 24 17 35 46 45 46 65 85
Total 190 195 228 221 245 294 307 345 322 489 602
a
Excludes methadone from 1993.
b
Excludes MDMA from 1993.
Source: Home OYce.
61 Sources of epidemiological information in the UK
Home Office Index
In the UK, the Home OYce Index used to be a further source of information
about addicts deaths because a separate list was kept of those addicts removed
from the current index by reason of death. By deWnition, the information referred
only to addicts known to the Home OYce in the Wrst place and, as already noted,
this list was by no means complete anyway. However, the Home OYce statistics
also included national statistics of deaths where the underlying cause was drug
dependence or nondependent use of drugs, or the use of controlled drugs (Table
2.8, Figs. 2.9, 2.10).
41
In 1995, the last year for which the Home OYce prepared the oYcial UK
mortality statistics, there were 1810 drug-related deaths nation-wide, according to
this Home OYce deWnition. Of these, about 600 (Table 2.8) were attributed to
drug dependence (ICD9 304) or nondependent misuse of drugs (other than
alcohol or tobacco but including volatile substances: ICD9 305). Four hundred
and seventy deaths were recorded as resulting from accidental poisoning
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1991 1992 1993 1994 1995
Year of registration of death
D
e
a
t
h
s
AIDS
Undetermined
poisoning
Suicidal poisoning
Accidental poisoning
Drug dependence and
abuse
Fig. 2.9 Causes of death of addicts known to the Home Office, UK 199195.
0
100
200
300
400
500
600
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995
Year of death
N
u
m
b
e
r
o
f
d
e
a
t
h
s
Males
Females
Fig 2.10 Deaths of addicts known to the Home Office by sex, UK 198595.
62 Drug dependence in the UK and elsewhere
(E850-E866) by controlled drugs and 260 involved controlled drugs where it was
undetermined whether the drugs had been taken purposefully or accidentally. In
addition, some 350 people committed suicide with controlled drugs.
Of the 602 deaths in 1995 resulting fromdrug dependence or the nondependent
misuse of drugs, about 53% used morphine-type drugs (including 19% involving
methadone) and about 7% used volatile substances. Fifteen per cent of those who
died were under 20 and about four Wfths were of people under the age of 35.
63 Sources of epidemiological information in the UK
The main Class A drugs (Misuse of Drugs Act 1971) used in accidental
poisoning deaths were methadone (154), morphine (97) and heroin (60). Benzo-
diazepines were involved in one sixth and dextropropoxyphene in one tenth of
such deaths. About a third of suicides caused by poisoning involved at least one
controlled drug. These were usually class C drugs, particularly dextro-
propoxyphene and benzodiazepines, and class B drugs, mainly dihydrocodeine,
codeine and barbiturates. Investigation of suicide using information from the
Home OYce Index showed that, over a 25-year period, addicts were at higher risk
of suicide than the general population and that prescribed drugs, notably anti-
depressants and methadone, inXuenced this heightened risk. The average annual
suicide rates among newly notiWed addicts for the period were 69 (males) and 44.8
(females) per 100,000 person years.
46
National Statistics
Figures published by National Statistics for England and Wales and by the General
Register OYces for the rest of the UK, are another source of mortality data,
classiWed using the Ninth Revision of the International ClassiWcation of Diseases
(ICD-9). Using the National Statistics standard approach, which is fairly similar
to the Home OYce deWnition except for the omission of AIDS deaths, there were
2922 deaths in England and Wales in 1998.
47
AIDS is of course a serious threat to
substance misusers who inject their drugs and, of over 17 200 AIDS cases reported
in the UK between January 1982 and June 2000, some 1380 (8%) probably
acquired the virus through injecting drugs and, of these, nearly 1000 had died by
the end of June 2000.
National database for misuse of volatile solvents
A national database on deaths associated with the misuse of volatile substances is
based at St Georges Hospital Medical School. The most recent reports show that
deaths decreased slightly from 79 in 1996 to 70 in 1998, about half the rate in
1990.
48
These reductions reXect a decline in deaths fromaerosols and glues, so that
the majority of solvent-related deaths are now due to gas fuels and butane gas
lighter reWlls. Altogether, volatile substances account for about 2% of all deaths of
those aged 1519 in the UK; they are much more common in males than females,
and in the North of England, Northern Ireland and Scotland. It can easily be
appreciated that this sort of information on emerging trends is particularly helpful
in planning preventive strategies.
National Programme for Substance Abuse Deaths
The National Statistics total of drug-related deaths in 1997 and 1998 can be
compared with a relatively new surveillance system, the National Programme of
64 Drug dependence in the UK and elsewhere
Substance Abuse Deaths (np-SAD), which was established in 1997. This pro-
gramme collects data direct fromcoroners and applies local expertise in mortality,
addictions and epidemiology to extract a comprehensive picture of drug-related
deaths in England and Wales. Rather than simply counting deaths where the
coroners verdict is drug dependence, or nondependent abuse of drugs, the
np-SADalso investigates the causes of death, drugs present at post-mortem, drugs
prescribed and whether the deceased was an addict or had a history of drug abuse.
In its latest report, np-SAD recorded 1296 drug-related deaths in 2000, a decrease
of 8% over the previous year
49
(Appendix 5).
Surveys
Surveys are widely used epidemiological tools to measure knowledge, attitude and
behaviour in diVerent populations. Where they are used in an assessment of
substance misuse, they can be applied to whole populations or restricted to
speciWc groups often identiWed by age. In the UK for example there are regular
surveys of peoples experience of crime, one component of which explores self-
reported drug misuse. The most recent published report covers the 1998 survey in
England and Wales
50
and oVers a measure of prevalence of drug misuse among the
general population. Young people aged 1629 reported the highest level of drug
misuse, with 49% saying that they had taken a prohibited drug at some time.
However, only 25% had taken drugs within the last year and only 16% within the
last month. Cannabis was the most widely consumed prohibited drug, with a
signiWcant increase between 1996 and 1998 in its use by young men. Other surveys
include those undertaken by the Health Education Authority Survey which fo-
cuses on assessing the level of knowledge of risks associated with drug misuse;
surveys of schoolchildren, surveys of adolescents and surveys of youth lifestyles.
Out of the wealth of information gained by such surveys, the following points
indicate the sort of areas that can be explored in this way and the information that
can be obtained.
Recent drug users were more likely to have started smoking earlier and were
twice as likely to describe themselves as fairly regular smokers. Recent drug users
drank alcohol regularly and were more likely to imbibe than those who had ever
used drugs (94% compared with 74%).
51
Of 930 Scottish schoolchildren aged 11 and 12 years, 105 (11.4%) reported
having used illegal drugs; there was a higher rate for boys (13.7%) than girls
(8.8%). Of those who had used drugs, 79.4% reported having used cannabis but
other drugs were extensively used too. Current use rates were much lower and
cannabis again dominated the picture. Use of drugs by a family member was found
to be an important factor inXuencing drug use by these young people.
52
By the age
of 13 years, over 90% of children could recognize the commonly used drugs; 60%
65 Sources of epidemiological information in the UK
of 14-year-olds and 80% of 16-year-olds had encountered or been oVered drugs.
In Northumbria the rate of drug-taking increased from 34% at the age of 13 years
to 51% a year later. The corresponding Wgures for West Yorkshire were 21% and
34% illustrating the diVerences that can occur just within one country. Volatile
substances and popping were features of drug-trying in early adolescence; LSD
and amphetamine were tried in mid-adolescence and ecstasy after the age of 16
years.
53
The 1998/99 Youth Lifestyles Survey looks at oVending behaviour including
unreported, unrecorded and undetected crime among people aged 1230 years,
interviewed in the British Crime Survey and those living at addresses next door.
54
About one third (32%) of males aged 1230 years reported ever having used drugs
compared with 22% of females, but there were big diVerences between diVerent
age groups. Only 3% of 12- to 13-year-olds had used an illegal drug, compared
with a peak of 54% among 21-year-olds. The level of oVending amongst drug
users aged 1217 years was 15 times higher than for nondrug users. Amongst 18-
to 30-year-olds, male drug users were twice as likely to oVend than nonusers
whereas the ratio was three to one for females in this age group. Serious or
persistent oVenders were more likely to use opiates or cocaine.
Accident and emergency (A & E) departments
As psychoactive drugs such as hypnotics, anxiolytics and antidepressants have
been prescribed more widely, the morbidity associated with their use has become
apparent. Undoubtedly, the most important morbidity in terms of sheer number
is that of drug overdose. Such is its frequency that the margin of safety betweenthe
therapeutic dose of a psychoactive drug and the dose required for serious overdose
or death is at times a property with commercial signiWcance.
The majority of cases of drug overdoses are seen in hospital A & E departments
which are, therefore, excellent places to study this particular morbidity, to moni-
tor the whole range of drug problems and, by including all who attend with a
drug-related problem, to identify trends in drug abuse in the general population.
These departments oVer several advantages for undertaking this kind of epi-
demiological research. Perhaps most important of all is the fact that although
administration and organization may vary, some sort of emergency facility exists
in all health care systems so that there is a ready-made, cost-eVective set-up
available, world-wide, ready to monitor drug-related problems. Another advan-
tage of A & E departments is that they are neutral ground for those with
drug-related problems. For those who have taken a drug overdose, for example,
the underlying psychosocial reasons are ignored, at least temporarily, while the
acute consequences of the overdose are treated by a medical team. It is probable
that patients seen in this neutral, comparatively nonjudgmental situation are
66 Drug dependence in the UK and elsewhere
more representative than those in more highly selective situations such as special-
ist drug treatment units, prisons or remand homes. The value of A & E depart-
ments as a neutral ground is enhanced by an awareness of medical conWdentiality
which facilitates the gathering of accurate data on sensitive issues. Nevertheless, it
must be noted that studies in these departments, while providing valuable infor-
mation about drug-taking in society as a whole, say little about individual
patterns.
If A & E departments are to be utilized on a large scale for this type of research,
the monitoring procedure must be planned very carefully. All studies must be
prospective in nature because notes taken during an emergency situation are
rarely suYciently detailed for comprehensive data to be gleaned from them
retrospectively. However, any prospective study must be aware of the busy
conditions prevailing in A & E departments and the questionnaire, designed to
elicit maximum information, should also be brief and simple so that the staV of
the department, whose main responsibility is to the patient and not to research,
can complete it easily.
An important decision to be made when planning the investigation is whether
to study incidents or individuals. When individual patients are identiWed, valuable
information is obtained about the comparatively small group of individuals who
attend A & E departments repeatedly. They are important partly because they
generate a lot of work and also because the health care response they initiate is
clearly inappropriate to their needs, suggesting that an alternative response should
be sought. However, having information that positively identiWes patients poses
diYcult problems of conWdentiality while that information is being processed.
The largest survey of A & E departments, both geographically and in terms of
duration, is that being carried out in the USA by the Drug Abuse Warning
Network (DAWN).
55
This receives reports from hospital emergency rooms, medi-
cal examiners (i.e. coroners) and crisis intervention centres, which provide some
indications of drug-abuse trends in large urban populations. A specially trained
reporter recruited from the staV of each hospital and located in the A & E
department is responsible for identifying patients with a drug-related problem
and for completing the DAWN questionnaire. This focuses on two main issues:
the drug(s) used and the drug user. As more than one drug may be used in a
particular incident, more drug mentions are recorded than drug-related inci-
dents; no identifying information about the patients is collected.
In contrast, a survey carried out in 1982 in A & E departments in London
speciWcally identiWed patients with drug-related problems by recording their
name, date of birth and address so that they could be traced if they presented to
hospital on more than one occasion during the period of the survey.
56
Information
was also elicited about the drug(s) of abuse and self-poisoning, the underlying
67 Sources of epidemiological information in the UK
reason for the drug overdose, the source of supply of drugs, their method of
administration and any history of drug overdoses taken in the 12 months prior to
the survey.
The potential of using A&E departments to monitor substance misuse has been
acknowledged in the National Plan, which has as one of its research objectives for
200001, to put forward proposals to examine the feasibility of collecting data on
drug-related attendances at Casualty Departments.
57
Because the picture is con-
stantly changing it is essential for epidemiological research to be regular and, in
some situations, continuous. In A&E departments, for example, ongoing research
could form a sensible early warning system to identify new drugs of abuse so that
responses could be swift and appropriate. Ideally such research should be taken in
several centres, even internationally, but then great care must be taken about the
data that is recorded. Soft data, such as the dependence status of the patient or the
motivation of an overdose, is diYcult to categorize even with careful operational
deWnitions so that there is always a large unknown group. In contrast, hard data
on age, sex and drug(s) taken is easy to elicit and record. However, even with hard
data a uniform system of tabulating results must be decided on in advance if valid
comparisons are to be made. For example, uniform age and drug classiWcation
systems are essential if research done in one department is ever to speak to that
done in another.
Other epidemiological approaches
There are many other potential sources of information about drug abuse. Individ-
ually, they often deal with highly selective groups of the population and provide
unrepresentative information. Together, however, they contribute to a more
complete picture about the trends in drug use and drug abuse.
Possible sources of information are:
Drug-dependence treatment, services, rehabilitation centres and voluntary agen-
cies. Various types of surveys in these places can provide information about the
characteristics of clients, treatment and outcome.
Toxicology laboratories. Now that reliable methods have been developed for the
qualitative and quantitative measurement of drugs in body tissues and Xuids,
toxicological analysis is playing an increasingly important role in providing Wrm
data about drug use. Where this is done, it is a good, cost-eVective method of
gathering data on drug-related health problems.
Hospital discharge diagnoses
Drug-related disease. One way of Wnding out about drug-related problems is to
monitor public health data on the frequency of reports of various types of
pathology such as HIV/AIDS, viral hepatitis, fetal damage, etc., on the assumption
Table 2.9. New AIDS cases notified to the end of June 2001, identifying the number who
acquired it through injecting drug use, UK
New AIDS cases notiWed
Year Total Injecting drug users
1985 or earlier 408 3
1986 474 7
1987 681 16
1988 908 28
1989 1082 64
1990 1244 82
1991 1387 88
1992 1578 84
1993 1785 153
1994 1851 139
1995 1764 151
1996 1425 118
1997 1064 77
1998 767 44
1999 715 27
2000 718 34
2001 142 6
Total 17 993 1121
There were also 311 AIDS cases notiWed involving sex between men who had also injected
drugs. These cases are not included in the injecting drug users column above.
Source: Department of Health.
68 Drug dependence in the UK and elsewhere
that these problems are suYciently closely linked to drug consumption to be
reasonable indicators (Table 2.9). The advantage of this method is its simplicity
and low cost, and if data is gathered promptly and routinely it should provide
early information about the extent of drug abuse. However, the simplicity and
economy are oVset by the lack of the speciWcity of a particular morbidity for
psychoactive drug abuse. To give an extreme example, it would be hopeless to try
and monitor drug abuse by reports of skin rashes many drugs can cause rashes as
can a variety of infections and allergic conditions.
58
It follows that the disease or
disturbance must be relatively speciWc for the drug in question and that the
majority of cases must be due to that drug.
Another diYculty is that monitoring of public health data depends on the
identiWcation of cases in diVerent centres with an epidemiological picture being
69 International information on drug abuse
built up by multicentre reporting of fairly low frequencies. Case deWnition and
case recognition will probably vary from centre to centre and may vary in time
with changing medical awareness. Other factors also combine to make morbidity
an unreliable indicator of drug abuse: the proportion of casualties presenting to
medical agencies may vary at diVerent times and at diVerent centres and the
percentage of those who take drugs and sustain a particular complication may also
vary from time to time. Hepatitis, for example, used to be a reliable indicator of
heroin dependence, but for a variety of reasons, now seems a much less certain
marker.
Because of diYculties such as these, attempts to design indirect indices of drug
misuse similar to those designed for alcohol are unlikely to succeed, although
speciWc morbidities can be useful in providing an early warning of new drugs
being misused, of geographical spread to new areas and of involvement of new
population groups. For example, public health laboratory services in the UK
publish a quarterly bulletin giving information on HIV/AIDS.
59
The most recent
issue has identiWed 6% of AIDS cases (1121/17993) being accounted for by
heterosexual injecting drug users and a further 2% (311 cases) by homosexual
injecting drug abusers. About 10% (3608/42125) of HIV cases were contracted by
heterosexual drug abusers and a further 2% (629 cases) by homosexual injectors.
International information on drug abuse
The problems of drug abuse that have preoccupied the UK during the last 30 years
have not been conWned to this country. There is a world-wide concern about all
aspects of drug abuse, although speciWc drug problems may be of greater import-
ance in some areas than in others.
The European Monitoring Centre on Drugs and Drug Addiction (EMCDDA)
was set up in 1993 to provide the European Union and its Member States with
objective, reliable and comparable information at European level concerning
drugs and drug addiction and their consequences. It is based in Lisbon and
became fully operational in 1995. The EMCDDAs main tasks include (a) collect-
ing and analysing existing data; (b) improving data-comparison methods; (c)
disseminating data and information; and (d) cooperating with European Union
institutions, international partners and with non-European Union countries.
60
The information processed by the Centre focuses on the following areas:
Demand and reduction of demand for drugs;
National and European Community strategies and policies;
International cooperation and the geopolitics of supply;
Control of the trade in narcotic drugs, psychotropic substances and precursors;
70 Drug dependence in the UK and elsewhere
Implications of the drugs phenomenon for producer, consumer and transit
countries.
In much of Europe, the changes in the patterns of drug abuse have been very
similar to those in the UK during the same period.
61
Cannabis, for example,
became popular in the 1960s in much of Western Europe as did LSD (Appendix
1(c)), although to a much smaller extent. Elsewhere, especially in Sweden, am-
phetamines were the preferred drugs and their intravenous use has become
common and remains a problem today. The inXux of illicit heroin into Europe
Wrst from South-East Asia, and later from South-West Asia, caused serious
problems of opiate dependence in many countries. In Poland, however, the
problemwas with home-grown heroin, prepared fromthe strawof opiumpoppies
which were grown quite legally to provide the poppy seeds found in so many
Polish dishes.
Other notable trends in drug abuse have been the rapid spread of cocaine and
solvent abuse and changes in the pattern of barbiturate abuse. The latter drugs,
once the cause of serious problems in several countries, have become less import-
ant as they are nowprescribed less and heroin has become so easily available. More
recently, as in the UK, benzodiazepines have largely taken their place as drugs of
abuse often used in combination with other drugs, particularly alcohol.
International audit
6269
One way of Wnding out about patterns of drug use is to investigate the supply
situation by obtaining information about the production of drugs and their
importation and exportation. In practice, reliable data can only be obtained about
licit sources of supply, but a global overview of the situation is maintained by the
International Narcotics Control Board (Chapter 12), which collects statistics on
drug production and consumption fromalmost all countries and collates this with
information about illicit drug activity internationally. Analysis of this data pro-
vides information on the development of new trends in drug consumption and
can give early warning of rapidly increasing use that might suggest abuse.
The World Customs Organization (WCO) and the International Criminal
Police Organization (Interpol) also have invaluable information on drug traYck-
ing and seizures.
Demand and supply of opiates for medical and scientific purposes
While focusing on the abuse of drugs, it should not be forgotten that many have
legitimate and important medical uses. Not least among these are the opiates,
which are widely used for the treatment of severe pain, particularly in cancer
patients. Despite the increasing use of morphine for this purpose, expansion and
diversiWcation of the licit opioid market has been somewhat slow during the last
71 International information on drug abuse
25 years and has not kept up with the increased requirements expected of a
growing population. However, the global consumption of opiates was relatively
stable in the Wve year period between 1995 and 1999, at an annual average of 241.5
tons in morphine equivalent. Thus global licit opioid consumption was 240 tons
in morphine equivalent in 1999. Of this, codeine is the most widely used natural
opioid used as a cough suppressant and an analgesic with an average annual
consumption of around 170 tons in recent years (173.4 tons in 2000), representing
about 75% of total licit opiate consumption. Between 1978 and 1998, global
codeine consumption increased at an annual rate of only 12%. As far as mor-
phine itself is concerned, global consumption for medical purposes was relatively
low and stable for many years up to 1984 when it amounted to about 2.2 tons.
Since then, it has risen almost 10-fold (20.2 tons in 2000). Global consumption of
dihydrocodeine, having stabilized at approximately 30 tons per annum in mor-
phine-equivalent for the last 6 consecutive years, declined in 2000 to 26.5 tons.
However, consumption of oxycodone has followed an upward trend, with a
gradual increase during the period 198095 followed by a sharper increase from a
level of 3 tons per annum to 12.8 tons in 1999 and 18.5 tons in 2000. Other
semisynthetic or synthetic opioids with signiWcant or increasing consumption
levels are buprenorphine, hydrocodone, hydromorphone and fentanyl.
62
However, these global Wgures for opiate consumption conceal signiWcant in-
equity of access to analgesics because morphine and its derivatives are not equally
available in all countries in the world. For example, the average per capita
consumption of morphine in 1998 in the 10 countries with the highest morphine
consumption levels, was 31 g per 1000 inhabitants; in the 10 countries with the
next highest consumption levels, the corresponding Wgure was 16 g per 1000
inhabitants; in the next 60 countries (whose total national morphine consumption
exceeded 1 kg), average per capita consumption was only 2 g per 1000 inhabitants.
In the remaining 120 countries there was little or no opioid consumption for licit
medical purposes.
Total licit global production Xuctuates from year to year, according to climatic,
social and political conditions. However, global production of opiate raw ma-
terials increased steadily from1996 to 1999 in terms of both the area harvested and
the quantity produced. The area harvested fell sharply in 2000 but the total
quantity of morphine-equivalent that was produced remained fairly steady (384.3
tons). In 2000, India was the major producer (146.2 tons morphine-equivalent),
closely followed by Australia (112.0 tons). Other producer countries are: France
(40 tons), Turkey (35.8 tons), Spain (34.8 tons), other countries (15.5 tons). The
production of opiate raw materials declined in 2001 and it is predicted that it will
reduce further in 2002.
It is important that a balance between production and licit requirements is
72 Drug dependence in the UK and elsewhere
maintained because this controls the amount of this highly prized drug that is
available for diversion to the black market. In fact, the amount of such diversion is
small in comparison with the volume of illicit transactions, indicating that
international control measures are largely eVective for this group of substances. In
1999 and 2000, production exceeded demand by about 160 tons; this permits the
maintenance of reserve stock so that opioid analgesic supplies can be maintained
even if the crop suVers a major failure.
63
Medical requirements and availability of psychotropic substances
Just as for opioid drugs, the national supply of psychotropic substances should
correspond as closely as possible to medical need. National drug requirements
may be assessed in a number of ways, including morbidity rates and regular
surveys of consumption, although both methods have their limitations.
58
Com-
parison of consumption data between countries and regions appears to be a useful
indicator and throws up some interesting diVerences. For example average per
capita consumption of benzodiazepines is much higher in Europe than in any
other region. SpeciWcally, in 199799, consumption of benzodiazepine-type seda-
tive hypnotics in Europe was four times higher than in America, six times higher
than in Asia and 25 times higher than in Africa. Similarly, benzodiazepine-type
anxiolytic consumption in Europe was one and half times that in America, three
times that in Asia and seven times that in Africa. However the consumption of
amphetamines and anorectic drugs is about 10 times higher in the USA than in
any country in Europe. Again, these intercontinental diVerences hide signiWcant
diVerences between countries in the same continent. It is worth noting that
excessive drug consumption that is medically unjustiWed and which occurs pre-
dominantly in industrialized countries, together with street / parallel / unregulated
markets, that occur predominantly in developing countries, have a number of
general and country-speciWc causes and driving forces, of which the most import-
ant are their commercial, sociocultural and educational environments. For
example newly gained wealth or aZuence appears to be associated with quickly
growing drug consumption in countries and territories experiencing rapid econ-
omic growth, e.g. Malaysia, Singapore, Thailand.
64,65
The diversion of psychotropic substances
The control of psychotropic drugs under the international conventions has been
less successful, resulting in large diversions of these drugs into the illicit market.
This has frequently involved drugs such as stimulants, sedative hypnotics and
tranquillizers, mainly in developing countries, and suggests that current control
mechanisms are inadequate. Moreover, for several years, some parties to the 1971
Convention on Psychotropic Substances (see Chapter 12), have failed to bring
0
100
200
300
400
500
600
700
800
900
1000
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Year
P
o
t
e
n
t
i
a
l
m
a
n
u
f
a
c
t
u
r
e
o
f
c
o
c
a
i
n
e
(
m
e
t
r
i
c
t
o
n
s
)
Fig. 2.11 Potential global manufacture of cocaine, 19912000. (Source: United Nations Drug Control
Programme (UNDCP).)
73 International information on drug abuse
some of these drugs under the control of national legislation, enabling traYckers
to exploit these gaps. Despite these setbacks, the world-wide reduction in stocks of
methaqualone in line with declining medical requirements is an example of how
the system can work well, and there has been a similar reduction in stocks of the
stimulant fenetylline.
Production (Figs. 2.112.13)
Global production of illicit drugs can be considered both in terms of the tons of
drugs produced and the areas under cultivation. Firstly it is interesting to note that
the global area devoted to opium poppy cultivation is at its lowest level since 1988
and was 17% lower in 1999 than in 1990, while the area under coca cultivation has
reduced by 14% over the same period. This suggests that eVorts at crop eradica-
tion and crop substitution are bearing fruit, although this is partly oVset by higher
yields per acre. The global production of opiumhas declined frommore than 5700
tons in 1999 to an estimated 4700 tons in 2000. This trend is due mainly to a
decrease in production in Afghanistan, which accounted for about 69% of global
production in 2000 compared with 31% in 1985, 41% in 1990, and 79% in 1999.
Opium production in Myanmar accounted for 23% of global production in 2000
while other countries in Asia continued to account for less than 5%, and Latin
America for about 3%. Thus, although a record harvest of opium in Afghanistan
in 1999 had an impact on global production in 1999, the rate of increase in the
1990s was lower than during the preceding decade.
In 1999 potential heroin production was more than 570 tons and the total
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1994 1995 1996 1997 1998 1999 2000
Year
P
r
o
d
u
c
t
i
o
n
o
f
i
l
l
i
c
i
t
o
p
i
u
m
(
m
e
t
r
i
c
t
o
n
s
)
Fig. 2.12 Global production of illicit opium, 19942000. (Source: UNDCP, 2001.)
0
100
200
300
400
500
600
700
1994 1995 1996 1997 1998 1999 2000
Year
P
r
o
d
u
c
t
i
o
n
o
f
i
l
l
i
c
i
t
h
e
r
o
i
n
(
m
e
t
r
i
c
t
o
n
s
)
Fig. 2.13 Global production of illicit heroin, 19942000. (Source: UNDCP, 2001.)
74 Drug dependence in the UK and elsewhere
amount of opiates seized amounted to 85 tons (in heroin equivalent), an intercep-
tion rate of 15%. Thus the potential availability of heroin to the world market in
1999 was about 500 tons in comparison with 360 tons in 1998 and 400 tons in
2000.
Global illicit coca production was more or less stable in 2000 compared with
75 International information on drug abuse
previous years. Globally, the potential annual manufacture of cocaine is assessed
to have Xuctuated between 800 and 900 tons per annum throughout the 1990s.
This stabilization is the result of decreasing trends in Peru and Bolivia which have
been oVset by an increase in Colombia. It is estimated that, in 2000, about 75% of
cocaine available in the world originated from Colombia, with Peru and Bolivia
accounting for 21% and 4% respectively.
Globally, it appears that the production of illicit opium and coca is concen-
trated in fewer countries than previously and, when viewed as a whole, the total
areas under production are remarkably small. Unfortunately, this only serves to
emphasize how so small an area can maintain global supplies and how easily this
could be moved, if conditions change in the current areas of production.
In contrast to the opium poppy and the coca bush, cannabis is grown widely all
across the world with signiWcant amounts growing wild, particularly in the
Commonwealth of Independent States, in the Russian Federation and in Kazakh-
stan. It is also grown indoors under conditions of intense (hydroponic) cultiva-
tion, in many industrialized countries. This has led to tetrahydrocannabinol
(THC) concentrations in cannabis increasing from 10% to 30% during the 1990s.
Trafficking (Figs. 2.142.20)
The extent of drug traYcking is assessed by drug seizures, which can be measured
in terms of their number, the amount seized and the countries reporting them.
Using such information, major drug traYcking routes can be identiWed:
From Afghanistan, via Pakistan, Iran, Turkey and the Balkans to Western
Europe: opiates;
From the Andean countries of South America to the USA, either directly or via
Mexico or the Caribbean: cocaine;
From Mexico to the USA: cannabis. Global cannabis seizures increased signiW-
cantly in 1999, reaching almost 4000 tons, an increase of 36% over 1998 and
46% above the average level recorded during the 1990s;
From Morocco to Spain and other European countries: cannabis resin. Global
seizures of cannabis resin amounted to almost 900 tons in 1999 and the main
consumer market continued to be Western Europe which accounted for 77% of
global volume.
Western Europe remains the primary source of amphetamine and Ecstasy-type
substances although, in recent years, Eastern Europe has emerged as an additional
manufacturing zone for amphetamine. However, stimulant seizure statistics re-
Xected a decrease for the Wrst time in 1999. The production of Ecstasy-type
substances remains more or less concentrated in WesternEurope and fromthere it
is traYcked world-wide. The second region where amphetamine is produced,
traYcked and consumed in large quantities is East and South-East Asia. Western
0
50
100
150
200
250
300
350
400
450
ATS Cocaine Heroin
1993 1992 1991 1990 1994 1995 1996 1997 1998
Fig. 2.14 Trends in global seizures of amphetamine-type stimulants (ATS), cocaine and heroin,
199098 (index: 1990=100). (Source: UNDCP, 2000.)
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
M
e
t
r
i
c
t
o
n
s
Fig. 2.15 Global seizures of cannabis herb, 199099. (Source: UNDCP, 2001.)
76 Drug dependence in the UK and elsewhere
Europe and East and South-East Asia have each accounted for approximately 40%
of global stimulant seizure volume in recent years and North America for about
20%. However, in 1999 a very large seizure (16 tons) occurred in China.
It is worth noting that, in recent years, there has been a proliferation and
diVusion of traYcking and a divergence from these now well-established routes.
In particular, various African countries are increasingly linked into the process.
Consumption (Figs. 2.212.23)
Estimates of drug abuse in diVerent countries are based on the frequency with
which they report drug problems in international monitoring surveys. Drugs
North America
South America
Southern Africa
Western Europe
Caribbean
Eastern Europe
South Asia
Central Asia and Transcaucasian Countries
West and Central Africa
East and South-East Asia
North Africa
East Africa
Central America
Oceania
Near and Middle East/South-West Asia
2,691,874
382,317
371,664
131,702
88,444
75,099
47,461
44,562
33,882
25,207
24,482
22,438
(67%)
(10%)
(9%)
(3%)
(2%)
(2%)
(2%)
(1%)
(1%)
(1%)
(1%)
9,319
6,375
4,557
Fig. 2.16 Percentage by region of seizures of cannabis herb in 1999 (kilograms). (Source: UNDCP,
2001.)
0
200
400
600
800
1,000
1,200
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
M
e
t
r
i
c
t
o
n
s
Fig. 2.17 Global seizures of cannabis resin, 199099. (Source: UNDCP, 2001.)
77 Global drug problems
come to light as problems because of demand for treatment, emergency room
attendances, their use in overdose, drug-related morbidity etc. as described
earlier in this chapter.
Global drug problems
A brief description of drug problems in other parts of the world is helpful in
putting the UKs problems into an international perspective. Knowledge of these
problems is gained frominformation about illicit drug production, traYcking and
consumption and although individual pieces of information may be of limited
value, together they can build up a useful picture.
Western Europe
Near and Middle East/South-West Asia
North Africa
Central Asia and Transcaucasia
North America
South Asia
Caribbean
Eastern Europe
East and South-East Asia
South America
East Africa
Southern Africa
Oceania
686,983
123,230
60,729
13,530
7,238
4,611
1,486
900
538
379
85
(76%)
(14%)
(8%)
(2%)
(1%)
(1%)
41
11
Fig. 2.18 Percentage by region of seizures of cannabis resin in 1999 (kilograms). (Source: UNDCP,
2001.)
0
5
10
15
25
20
30
40
35
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Year
M
e
t
r
i
c
t
o
n
s
Fig. 2.19 Global seizures of amphetamine-type stimulants (excluding Ecstasy), 199099. (Source:
UNDCP, 2001.)
78 Drug dependence in the UK and elsewhere
Africa
Cannabis is the main problem drug in treatment demand in Africa and there is
illicit cultivation in 22 countries in the continent. Indeed, Morocco is the worlds
largest producer of hashish (cannabis resin) while Nigeria and South Africa are
major sources of marijuana. Both forms of cannabis are produced for domestic
consumption and for smuggling primarily to Europe. According to Interpol,
22% of the cannabis herb seizures made worldwide in 2001 were eVected in Africa
with Morocco as the source of 6070% of cannabis seized in Europe.
There is a long history of the abuse of psychotropic drugs, particularly stimu-
lants, and particularly in West Africa and this remains a problem, with the bulk of
drugs being smuggled in from Europe. Methaqualone is mainly abused in south-
Western Europe
Near and Middle East/South-West Asia
North America
West and Central Africa
Eastern Europe
North Africa
East and South-East Asia
Oceania
25,344
3,765
3,590
395
258
228
96
25
(75%)
(11%)
(11%)
(1%)
(1%)
(1%)
Fig. 2.20 Percentage by region of seizures of synthetic-type stimulants (excluding Ecstasy) in 1999
(kilograms). (Source: UNDCP, 2001.)
Amphetamine
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Ecstasy
1998 1996 1994
Fig. 2.21 Use of stimulants in Spain. (Source: Observator o Espan ol Sobre Dragos, Informe 3, Madrid,
2001.)
79 Global drug problems
ern and East Africa and to some extent in West Africa. It is estimated that up to
80% of the methaqualone illicitly manufactured world-wide may be abused in
South Africa.
However, the abuse of opiates and cocaine is increasing in Africa and, in Egypt
for example, where hashish has long been the main problem drug, opiates became
prominent in the 1990s, accounting for 45% of all cases in treatment, followed by
benzodiazepines (32%). While opiate abuse is beginning to show up on the
eastern coast of Africa, down to South Africa, cocaine abuse is more common in
0
1000
2000
3000
4000
5000
6000
7000
1995 1996 1997 1998 1999
N
u
m
b
e
r
o
f
p
e
o
p
l
e
Amphetamines
Ecstasy
Fig. 2.22 Use of stimulants in Germany (combined result of new and old provinces weighted by size
of population), annual prevalence (age 1859 years), 199599. (Source: UNDCP, 2000.)
1992
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
Amphetamines among general population (16-59 years old)
Amphetamines among 16-29 years old
Ecstasy among 16-29 years old
1994 1996 1998
Fig. 2.23 Use of stimulants in the UK (annual prevalence), 199298. (Source: Home Office, Drug
Misuse Declared in 1998: British Crime Survey, 1999.)
80 Drug dependence in the UK and elsewhere
81 Global drug problems
western Africa, again extending to southern Africa. Indeed, in the Republic of
South Africa cocaine accounts for 15% of all treatment demand compared to only
3% for opiate abuse and the abuse of crack is growing faster than the abuse of any
other drug; the abuse of MDMA (Ecstasy) is also spreading in South Africa.
The countries of West Africa are increasingly linked into the traYcking routes
for cocaine (and heroin) from South America to Europe and the spillover from
these markets is undoubtedly inXuencing the nature of drug-related problems that
are now being reported. In addition, in Nigeria, the use of Zakami (Datura
metel), a plant that grows wild in some parts of the country, is an emerging
problem.
In the Horn of Africa, khat (Catha edulis) poses a diVerent problem. Its trade
and consumption are not prohibited or controlled by international treaties, and it
is grown in Ethiopia, Kenya and Yemen. Although most is consumed locally,
freeze-driedand vacuum-packed leaves are shipped to Europe and some countries
have introduced national control measures to prevent its importation. Within the
Horn of Africa, large scale consumption of khat is reXected in treatment demand.
Drug abuse appears to be increasing in most countries in Africa; speciWcally, the
age of initiation to drug abuse is falling and the number of women and children
abusing drugs is growing. Although the rate of injecting drug abuse is still
relatively low, this practice is particularly worrying because the prevalence of
HIV/AIDs is high in most parts of the continent. In South Africa for example,
there has been a 40% increase in the number of injecting heroin abusers over the
last 3 years.
South America
Despite signiWcant reductions in the extent of illicit coca bush cultivation in
Bolivia and Peru in recent years, the overall capacity of the region to manufacture
cocaine does not seem to have been signiWcantly reduced. Indeed, the illicit
production, manufacture, traYc and abuse of cocaine is the cause of serious
economic and social problems in several South American countries with Colom-
bia, Peru and Bolivia accounting for 98% of global coca leaf cultivation. However,
within these three countries there has been a marked shift in production and
Colombia, which used to be the smallest producer, is now the largest. The reasons
underlying this change are interesting because they demonstrate how several
diVerent events interlink. In Peru, which used to be the main source of coca leaves
and coca paste for conversion to cocaine hydrochloride in Colombia, government
action to curtail illicit cultivation was aided by a fungus infection that destroyed
most of the crop. At the same time, air transport of coca paste between these two
countries was successfully interrupted, leaving the cocaine laboratories in Colom-
bia without easy access to their source material. However, the ongoing civil war in
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
1994 1995 1996 1997 1998 1999
Year
S
e
i
z
u
r
e
s
o
f
C
o
c
a
i
n
e
i
n
K
g
Fig. 2.24 Global seizures of cocaine. (Source: UNDCP.)
82 Drug dependence in the UK and elsewhere
Colombia and the consequent political instability facilitated the expansion of
domestic cultivation on a large scale and, although the Colombian government
has a comprehensive plan including extensive eradication programmes (Plan
Colombia), it has not been possible to reduce signiWcantly production of cocaine
hydrochloride. Furthermore, rather than exporting all of their coca leaves and
paste to Colombia, some is now utilized within Peru and Bolivia for the domestic
production of cocaine hydrochloride although this is on a very small scale in
comparison with Colombia, which accounts for 90% of all cocaine hydrochloride
seizures in the Andean region (Appendix 1(a)). Seizures of cocaine and its
derivatives in Colombia amounted to 64 tons in 1999 and this increased by more
than 100% in 2000, with seizures of coca leaf also increasing by almost 200%. In
2000, according to Interpol, the countries in the Andean subregion produced an
estimated 700900 tons of cocaine (Figs. 2.24, 2.25).
With this level of local production, it is not surprising that cocaine-type
substances (cocaine hydrochloride, crack cocaine and related products) are the
main problemdrugs in South America, responsible for 61% of treatment demand
and accounting for most drug-related violence and crime. Nevertheless, drug
problems in South America are not conWned to cocaine. Cannabis is cultivated in
most countries, mostly for domestic consumption and, in addition, illicit poppy
cultivation has been introduced because the associated proWts are higher than
those from growing cocaine. Indeed, Colombian heroin production, although
small in global terms, is important regionally and has substituted for South-East
Asian heroin in the lucrative US market; in the late 1990s, 65% of heroin seized in
1
2
3
29
63
101
107
361
370
12,133
16,723
43,707
118,113
168,591
(3%)
(5%)
(12%)
(33%)
(47%)
South Asia
East Africa
North Africa
East and South-East Asia
West and Central Africa
Near and Middle East/South-West Asia
Oceania
Eastern Europe
Southern Africa
Caribbean
Central America
Western Europe
South America
North America
Fig. 2.25 Percentage by region of seizures of cocaine in 1999 (kilograms). (Source: UNDCP, 2001.)
83 Global drug problems
the USA originated in Colombia. Although heroin seizures have signiWcantly
increased in recent years in Colombia, the abuse of heroin in most countries in
South America continues to be negligible. Argentina and Chile have the highest
prevalence of cocaine abuse in the region and it is estimated that in Rio de Janeiro
approximately 3000 street children are involved in drug traYcking.
Solvent abuse poses major problems in many South American countries,
particularly among the large population of street children in the urban slums. The
abuse of tranquillizers is widespread in Peru and Bolivia but there is very little
statistical data from other countries. Seizures of MDMA (Ecstasy) have become
more common and this substance has become fashionable among the youth of
several countries in the region.
Central America and the Caribbean
The strategic location of the Caribbean region has led to its being an important
transit area for cannabis and cocaine being imported into North America and, to a
lesser extent, into Europe. Indeed, transit traYc in cocaine constitutes the greatest
drug problem in the region and this has led to domestic drug problems too, with
an associated increase in drug-related deaths. It is estimated that nearly half of the
cocaine that arrives in the USA each year (approximately 375 tons) comes through
Central America and the Mexican land corridor. However, drug traYckers have
diversiWed their activities from cannabis and cocaine to psychotropics (mainly
MDMA) and heroin. There is a long history of cannabis cultivation in the region
and this continues today; most is intended for local use leading to high levels of
problem drug use, although some is smuggled into the USA and Canada.
North America
Cannabis is the most commonly abused drug in North America, with signiWcant
amounts being smuggled in from South and Central America. It is estimated that
84 Drug dependence in the UK and elsewhere
there were over 19 million cannabis users in the USA alone in 1997, and cannabis
accounts for 23% of demand for treatment. This reXects the high concentration of
THCin cannabis that is grown hydroponically in the USAand Canada which leads
to higher morbidity rates, and also the fact that some cannabis users have
treatment orders as a result of court cases. The use of cannabis increased only
slightly in 1999 which was considered not to be signiWcant by the US Household
Survey. Both annual and monthly prevalence rates in the USA are signiWcantly
below the levels reported a decade earlier and, as there has not been a signiWcant
increase in Canada and Mexico, cannabis use in North America as a whole can be
considered stable. However, the use of cannabis in combination with stimulants is
increasing in both the USAand Canada, including the practice of smoking blunts
(cannabis packed in cigar wrappers) which are dipped in phencyclidine (PCP).
Although cannabis remains important in terms of the numbers using it, cocaine
is the main problem drug in North America, accounting for more than 40% of
treatment cases. Several multi-ton seizures of cocaine were made in the PaciWc in
2001, including one that amounted to 13 tons the largest maritime seizure ever
made. Against this background, it is perhaps not surprising that the estimated
number of cocaine users in the USA alone in 1997 exceeded 4 million, including
more than 1 million crack cocaine users. Despite these large numbers, the overall
level of cocaine abuse in the USA remained unchanged between 1998 and 1999,
with an annual prevalence rate of 1.7%of the population aged 12 years and above,
and a monthly prevalence rate of 0.8%. All of the indicators show a decline in
cocaine use in the USA with the rate of cocaine abuse among adolescents declining
by 14% during the same period. The serious nature of cocaine-related problems is
reXected in the demand for treatment that it generates, although there are signs
that the latter is also decreasing. Thus in 1997, 222 000 people were treated for
cocaine abuse (29% of all demand for treatment) compared with 267 000 people
(40%) in 1992. Most demand for treatment was related to crack cocaine.
In Mexico, the abuse of cannabis, cocaine and heroin is increasing although it
has remained at a level that is considerably lower than in Canada and the USA.
In comparison with cannabis and cocaine, relatively small numbers abuse
opiates in North America. For example, in 1997, there were an estimated 597 000
abusers in the USA; nevertheless they generated more than 25%of all demands for
treatment. Overall, heroin abuse has declined due, it is claimed, to the eVect of
educating people about the harmful consequences of drug abuse.
In addition to methamphetamine abuse, which is widespread in western Cana-
da and the USA, MDMA of Western European origin is increasingly being abused
by young people in North America. It has spread beyond the rave scene to other
settings and other age groups such as schoolchildren as young as 12 years old.
There has also been an increase in abuse of other club drugs such as ketamine and
85 Global drug problems
GHB (gamma hydroxy-butyric acid) which have just come under international
control. In addition, there is evidence of increasing abuse of methylphenidate by
adolescents, who steal or purchase tablets from children being treated for atten-
tion deWcit hyperactivity disorder (ADHD). Potentially, this is a huge source of
stimulant drugs for abuse because of the massive increase during the 1990s in the
diagnosis and pharmacological treatment of ADHD in the USA, which now
accounts for 90% of global manufacture and consumption of this drug (913 tons
per year). Altogether, in the USA in 1999, nine million persons over the age of 12
years had abused prescription drugs, including opioids, depressants and stimu-
lants and widely prescribed oxycodone and amphetamine-type stimulants are
Wnding their way to illicit markets.
East and South-East Asia
South-East Asia continues to be a major producer of illicit opium, with poppy
cultivation taking place mainly in Myanmar. Indeed, in 2001, following the ban on
opium cultivation in Afghanistan, Myanmar accounted for most of the worlds
illicit poppy cultivation. Although the Lao Peoples Democratic Republic is
another large producer, the area under opium poppy cultivation has been success-
fully reduced in China and in the northern provinces of Viet Nam. There have also
been major changes in the traYcking patterns in this part of the world. Tradition-
ally, the so-called Golden Triangle was the major outlet for heroin from South-
East Asia, with Thailand accounting for almost 60% of all seizures in the late
1980s. A decade later, this had fallen to only 5%, but seizures in the Peoples
Republic of China increased from 4% to 77% over the same period. Most of these
seizures were of heroin that had originated in Myanmar and were intended for the
North American market, via Hong Kong and Taiwan, although more is now used
within China itself. Interestingly, a poor opium harvest in 1999 led to a sharp
downturn in seizures in the region. The abuse of opiates remains a serious
problem, in particular in China, the Lao Peoples Republic, Myanmar and Viet
Namand there continues to be a relationship betweentraYcking in heroin and the
prevalence of heroin abuse.
Interestingly, HIV of the same viral subtype is found to have spread along the
length of the traYcking route; this is closely linked to the spread of drug abuse by
injection. At the same time many new drug abusers are increasingly choosing to
ingest substances such as MDMA (Ecstasy) in tablet formor to inhale the fumes of
methamphetamine. The wide availability of and increasing illicit demand for
amphetamine-type stimulants has been conWrmed by the number of seizures,
which has increased sharply in the region since the end of the 1990s. A new
development is the increasing abuse of ketamine in dance clubs in some cities in
South-East Asia.
86 Drug dependence in the UK and elsewhere
Stimulant abuse is common in several countries in East Asia, most notably
Japan, the Republic of Korea and the Philippines, where methamphetamine is the
main problem drug, accounting for more than 90% of treatment demand. In
Thailand too, where opiates have long been the main problemdrug, the number of
methamphetamine users is now thought to exceed the number of heroin users.
Recently there have been sharp increases in the number of MDMA abusers in
some countries in the region. Most of the MDMA has been manufactured in
European countries but some laboratories in the border area between Myanmar
and Thailand may already be manufacturing relatively inexpensive MDMA for
local abuse (Appendix 1(d)).
South Asia
The opium poppy is cultivated legally in India, and small quantities are diverted
into illicit channels. At one time, far greater problems were posed in this region by
transit traYc in heroin from South-West and South-East Asia. However, this
appears to have been reversed and, over the last decade, seizures of heroin and
morphine in India fell by over 60%. Nevertheless it is estimated that there are
about 3 million people abusing opiates in India, representing a prevalence rate of
0.5%. Heroin abuse has been accompanied by increased evidence of HIV infec-
tion. Heroin abuse is also a serious problem in Nepal and Sri Lanka, and has been
reported in urban slums in Bangladesh. Buprenorphine is abused in a number of
countries in the region and, in Bangladesh, its abuse by injection largely accounts
for the increasing number of individuals who abuse drugs by injection.
There is large-scale cannabis cultivation in parts of Sri Lanka, while Nepal
remains an important source of cannabis resin for countries in Europe as well as
India.
Cocaine abuse remains very limited in South Asia although the number of
seizures has increased in recent years, particularly in India.
Growing abuse of psychotropic substances has been reported by every country
in the region and, on average, about 10% of all drug abuse in India involves
prescription drugs. Although there has been a decline in the illicit manufacture of
methaqualone in India, the seizure of tablets of Indian origin has been reported in
South Africa; methaqualone abuse has also started to spread in those African
countries that serve as transit points. There has been a signiWcant increase in the
Xow of ephedrine into Myanmar from India and Xow of methamphetamine
through the traditional heroin route from Myanmar to India an indication that
the abuse of amphetamine type stimulants may become a problem in India.
West Asia
Afghanistan and neighbouring parts of Pakistan appear to be the main sources of
large quantities of cannabis resin that is smuggled into Europe along various
1989
70
60
50
40
30
20
10
0
M
e
t
r
i
c
t
o
n
s
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Fig. 2.26 Global seizures of heroin and morphine, 198999. (Source: UNDCP, 2000.)
87 Global drug problems
traYcking routes. There is also considerable illicit traYc in cannabis in CIS
member states, with cannabis growing wild over extensive areas in Kazakhstan and
in the Russian Federation. The illict cultivation of cannabis in the Bekaa valley in
Lebanon, which had been eradicated in the early 1990s, was resumed in 2001.
As well as being involved in the production of cannabis, Afghanistan accounted
for 79%of global opiumproduction in 1999. The combination of drought and the
implementation of successful programmes reduced its production by 28% in 2000
to about 3300 tons, with a signiWcant impact on the world market. However, it is
estimated that Afghanistan holds stockpiles equivalent to 23 years supply. A
decree in July 2000 totally banned the cultivation of the opium poppy in Afghani-
stan, which led to a major reduction in new supply. Production by Afghanistan in
2001 is estimated to have been in the region of 200 tons, which is comparable to
the amount of opium produced in the mid-1980s. However, opium poppy
cultivation increased again at the end of 2001. At the time of writing, there is
uncertainty about the future contribution of Afghanistan to the global illicit
market.
For many years Afghanistan has been the main source of opium and heroin for
its neighbouring countries (Iran, Pakistan, India, Central Asia) as well as for
Easternand Western Europe. The traYcking routes have proliferated steadily via
Iran, Turkey, Pakistan, Central Asian republics and more than half of the world
seizures in 199798 were made in South-West Asia, with Iran accounting for 9%
of seizures in 198788 and 42% in 199798. In 1999 Iran accounted for 80%of the
total amount of opium seized in the world and 90% of the total morphine seized.
For the Wrst time it seized more heroin than any other country in West Asia (Figs.
2.26, 2.27). These increases reXect a number of diVerent factors: increased produc-
tion of opium in Afghanistan, the increasing use of Iran as a traYcking route and
9
25
27
55
104
125
690
968
1,366
1,449
1,454
1,553
6,710
12,175
34,330
(1%)
(2%)
(2%)
(2%)
(2%)
(3%)
(11%)
(20%)
(56%)
Southern Africa
North Africa
Caribbean
East Africa
Central America
West and Central Africa
Oceania
South Asia
Central Asia and Transcaucasia
South America
Eastern Europe
North America
East and South-East Asia
Western Europe
Near and Middle East/South-West Asia
Fig. 2.27 Percentage by region of seizures of heroin and morphine in 1999 (kilograms). (Source:
UNDCP, 2001.)
88 Drug dependence in the UK and elsewhere
the increased eVorts of the Iranian authorities to stop traYcking. The eVects of the
increased production of heroin locally (Appendix 1(a)) are only too clear in
Pakistan, where opium abuse used to be the most common form of substance
abuse; this was superseded by heroin abuse by inhalation (chasing the dragon),
which in turn, since the late 1990s, has been overtaken by the injection of heroin as
the preferred route of administration. The ban on opium cultivation in Afghanis-
tan has had a signiWcant impact on the illicit market for opium, leading to a
relative shortage of opium and opium residue in Iran and Pakistan. Although the
purity of heroin decreased, the proportion of heroin abusers continued to increase
since heroin was more available than opium.
The abuse of benzodiazepines, often in conjunction with opium and heroin, is
widespread in Afghanistan and Pakistan. The Xow of illicit drugs, in particular
heroin from Afghanistan, in the countries of Central Asia increased in 2001 where
there are indications of a serious increase in the number of drug abusers and a
rapid increase in drug abuse by injection. In Uzbekistan, for example, the number
of injecting drug abusers doubled between 1998 and 2001 and, in Tadjikistan,
Turkmenistan and other Central Asian Republics, there has been a rapid increase
in the number of people abusing opiates.
Although the extent of cocaine abuse and traYcking in West Asia remains
insigniWcant, numerous seizures of small quantities of cocaine have been made in
countries in the eastern Mediterranean area, in Lebanon, Israel and Turkey. The
abuse of stimulants, including amphetamine, metcathinone and fenetylline (Cap-
tagon) is endemic in parts of West Asia and in 2000 there were signiWcant seizures
of MDMA in Israel and Turkey and CIS member states.
89 Global drug problems
Europe
Cannabis remains the main drug of abuse in Europe, with huge quantities being
smuggled in from Africa and West Asia. There is also a more local indoor source
in the Netherlands and, to a lesser extent in the UK, Germany, Scandinavian
countries and Eastern Europe. This is associated with varieties of cannabis with a
very high THC content, ranging from 1030% in the 1990s compared with 57%
before then. Albania has continued to be a major source of cannabis herb and, in
2001, illicit opium poppy cultivation was discovered there for the Wrst time. It has
been estimated that there are more than 22 million cannabis users in Europe,
representing 3.5% of the population aged 15 years or more.
The cultivation of poppy for culinary purposes has been traditional in countries
such as Poland and some of the CIS republics; a recent development is the use of
poppy straw to prepare an abusable extract of opium (Kompot or liquid
heroin). This practice has long been endemic in Poland but is now spreading to
other countries. However, Afghanistan is the major source of illicit heroin in
Europe, accounting for 7090% of the market there. The turmoil in the former
Yugoslavia and the opening of borders of former socialist countries has led to
considerable diversiWcation in traYcking routes.
France uses buprenorphine for long-term opioid maintenance treatment on a
wider scale than most other countries and has about 55 000 injecting drug users on
buprenorphine maintenance on the basis of a belief in its lower abuse liability and
low diversion potential. All physicians are allowed to prescribe buprenorphine for
maintenance therapy. However, recent studies show that a signiWcant proportion
self-inject and more stringent regulation has been recommended. Some other
European countries have now also started to use buprenorphine for the treatment
of opioid dependence. However, whereas in France this is within a low threshold
policy, Germany has adopted a high threshold policy.
A newer problem is the increasing traYc in and abuse of cocaine in Europe,
most of it originating in Colombia. The main entry points are in Spain and the
Netherlands, which together accounted for 63% of all European cocaine seizures
in 199798. However, increasingly, other cities in Portugal, the UK, Germany,
Italy, Belgium, France and Switzerland are being used as well as seaports in the
Nordic and Baltic countries demonstrating yet again the continuing diversiWca-
tion of traYcking routes. This illegal market has, until now, been less well
organized than in North America, but there is some evidence emerging of the
growing involvement of criminal groups fromColombia, Russia and Italy. Despite
this growth, cocaine seizures in Europe still account for less than 11%of the global
total (Fig. 2.28).
Other important drug problems in Europe include the illicit manufacture
of amphetamines (Appendix 1(b)) and of hallucinogenic amphetamines (e.g.
0.2
0.2
0.6
0.7
0.7
1.0
1.4
1.7
1.7
3.0
Finland (1998)
France (1995)
Germany (1997)
Netherlands (1998)
Canada (1997)
UK (1998)
Australia (1998)
Spain (1997)
USA (household survey 98)
USA (ONDCP (98)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Fig. 2.28 Cocaine abuse in North America, Australia and Europe, annual prevalence (percentage of
youth and adult population). (Source: UNDCP, 2000.)
90 Drug dependence in the UK and elsewhere
Ecstasy), which are traditionally used by young adults in nightclubs and all-night
parties. A worrying trend of the late 1990s is the extent to which the production of
Ecstasy is spreading outside Europe, to Israel, South America, South Africa and
Australia and also the extent to which European Ecstasy is traYcked outside
Europe with huge increases reported fromseveral regions. Seizures of MDMA and
similar synthetic drugs increased during 2000 throughout Western Europe, with a
large number of seizures in France, Germany and the UK. In France, for example,
the number of seizures doubled during 2000. However seizure statistics for 2000
show a decline in amphetamine seizures for the second successive year.
Finally, it should be noted that the long-standing drug problems in Europe have
been compounded by the political changes there. Factors such as the relaxation of
border controls, both in and between Western and Eastern Europe; growing
international trade with CIS countries, which frequently lack appropriate drug
control mechanisms and where drug-associated crime is increasing at a formi-
dable rate; the war in former Yugoslavia and the consequent political instability;
all make the traYc in illicit drugs much easier to conduct than formerly.
Oceania
Although substance misuse does not constitute a major problem in many parts of
this region, PaciWc islands are increasingly being used as transit points. Cannabis is
cultivated in Australia and New Zealand but in addition to this some is smuggled
in from Papua New Guinea and fromSouth-East Asia. Heroin comes in fromAsia
while cocaine originates in South America. Illicit traYcking in and abuse of heroin
continue to be serious problems in Australia. Seizure data indicate that it remains
Table 2.10. Estimated global number of drug abusers (annual prevalence) in the late 1990s
Illicit drugs of
which: Cannabis
Amphetamine-type
stimulants
a
Cocaine
Opiates of
which: Heroin
Global (million people) 180 144.1 28.7 14 13.5 9.2
As percentage of global
population
3.0 2.4 0.5 0.2 0.2 0.15
As percentage of global
population age 15 years
and above
4.2 3.4 0.7 0.3 0.3 0.22
a
Amphetamines (methamphetamine and amphetamine) and substances of the ecstasy group.
As drug users frequently take more than one substance, the total is not identical with the sum of the
individual drug categories.
Source: UNDCP, DELTA.
91 Global drug problems
widely available, that its price has fallen and its purity remains high. With the
exception of Australia, the availability of and demand for cocaine are low in this
region. In 2000 the total amount of cocaine seized in Australia reached a record
high level, more than twice the total amount seized in 1999. Stimulants such as
amphetamine are manufactured illicitly, mostly for markets in Australia and New
Zealand, while hallucinogenic amphetamine abuse is becoming more common,
mostly under the control of gangs of motorcyclists. The demand for MDMA has
been increasing in New Zealand.
Summary
The global picture of drug abuse seems to have two major components which used
to be quite distinct, but which have now merged. There is the traditional form of
drug abuse using crude plant material which contains only a low concentration of
active drug. This type of abuse by adults of opium, coca and cannabis has been
going on for centuries and continues today in the areas where the plant is grown.
In addition, there is the abuse of highly potent, synthetic or semisynthetic
substances mostly by young people in industrialized countries who often abuse
several diVerent types of drugs. It is this latter type of drug abuse that has been
spreading rapidly world-wide and that has been given back to the countries where
the traditional use of the drug originated. Thus Thailand and Pakistan now have a
major problem with heroin abuse and Bolivia with cocaine abuse.
It is now apparent that the distinctions that used to be made between producer/
supplier and consumer countries no longer have any meaning. Consumer coun-
tries are simultaneously suppliers of other drugs, while those that supply the world
0
20
40
60
80
M
i
l
l
i
o
n 100
120
140
160
Global Asia Americas Africa Europe Oceania
0%
Number of people (in millions)
In % of population age 15 and above
5%
10%
15%
20%
25%
Fig. 2.29 Estimated number of cannabis abusers (annual prevalence) in the late 1990s. (Source:
ODCCP, World Drug Report 2000.)
0
5
10
15
20
M
i
l
l
i
o
n
25
30
Global Asia Americas Europe Africa Oceania
0.0%
Number of people (in millions)
In % of population age 15 and above
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
Fig. 2.30 Estimated number of amphetamine abusers (annual prevalence) in the late 1990s.
(Source: ODCCP, World Drug Report 2000.)
92 Drug dependence in the UK and elsewhere
markets themselves import drugs. The notion of transit countries is also some-
what out of date as they are often involved in both supply and consumption too.
Underlying this globalization of the drug abuse problem is the internationaliz-
ation of, and cooperation between, the powerful drug cartels. They are skilled at
identifying the weak links in the international drug control measures countries
that are not parties to the international drug control treaties (see Chapter 11) and
those that have not fully implemented their provisions. They take advantage of
0
1
2
3
4
M
i
l
l
i
o
n
5
Global Asia Americas Africa Europe Oceania
0.0%
Number of people (in millions)
In % of population age 15 and above
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
Fig. 2.31 Estimated number of Ecstasy abusers (annual prevalence) in the late 1990s. (Source:
ODCCP, World Drug Report 2000.)
0
1
2
3
5
4
M
i
l
l
i
o
n
6
7
8
10
9
11
12
13
14
15
Global Asia Americas Africa Europe Oceania
0.0%
Number of people (in millions)
In % of population age 15 and above
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
Fig. 2.32 Estimated number of cocaine abusers (annual prevalence) in the late 1990s. (Source:
ODCCP, World Drug Report 2000.)
93 Global drug problems
countries that, because of political unrest, terrorist activities or civil war, are
unable to ensure governmental control over some parts of their territories and to
maintain adequate law enforcement, customs and pharmaceutical control.
Certainly as drug abuse spreads throughout the world, the target population is
deWnitely the young. At Wrst it was predominantly young males that became
involved often students and drug use often became associated with protest
movements. It soon spread, however, to involve those from deprived social
backgrounds as well, and to involve nearly as many females as males.
When these broad trends in the patterns of drug abuse are considered against a
background of global demographic trends, it is possible to make some guesses
about what will happen to drug abuse in the future. It seems likely, for example, in
0
1
2
3
5
4
M
i
l
l
i
o
n
6
7
8
10
9
11
12
13
14
15
Global Asia Americas Africa Europe Oceania
0.0%
Number of people (in millions)
In % of population age 15 and above
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
Fig. 2.33 Estimated number of opiate abusers (annual prevalence) in the late 1990s. (Source:
ODCCP, World Drug Report 2000.)
0
1
2
3
5
4
M
i
l
l
i
o
n
6
7
8
10
9
Global Asia Americas Africa Europe Oceania
0.00%
Number of people (in millions)
In % of population age 15 and above
0.20%
0.25%
0.15%
0.10%
0.05%
0.30%
Fig. 2.34 Estimated number of heroin abusers (annual prevalence) in the late 1990s. (Source:
ODCCP, World Drug Report 2000.)
94 Drug dependence in the UK and elsewhere
industrialized countries, with a falling birth rate and an aging population, that
there will be an increase in drug abuse by the elderly, which is most likely to
involve prescribed drugs. In contrast, in many poor countries with an exploding
birth rate, there will be a massive increase in the juvenile and young adult
population just at the time when illicit drug abuse is becoming entrenched. Never
has there been a greater need for eVective, preventive action.
6269
95
3
Drugs of abuse and dependence
Opioids
The parent drug of this class is opium, obtained from the opium poppy Papaver
somniferum, which grows in large areas of South-East Asia and the Middle East
(Turkey, Iran, Afghanistan, Pakistan, Myanmar, Thailand, etc.), as well as in other
parts of the world (e.g. Poland). After the poppies have bloomed, the unripe seed
capsules are incised with a knife and the milky exudate that oozes out is allowed to
dry. It becomes a brown, gummy mass which is scraped by hand from the seed
capsule. This, dried further and then powdered, is crude opium which may be
smoked in special pipes, chewed, or inserted as small pellets into cigarettes.
Prepared opium is a boiled-down aqueous solution of raw opium, prepared for
opiumsmokers by repeated boiling and Wltration to extract all possible opium and
to remove all impurities. The Wnal boiling leaves a thick, sticky paste.
Crude opiumcontains a number of chemical compounds called alkaloids which
possess the same or similar properties as opium. The major alkaloids obtained
from opium include morphine (10% by weight) and codeine. Traditionally, the
term opiates was used to describe these naturally occurring substances and the
semisynthetic drugs that are derived from them (e.g. diamorphine/heroin) while
opioids described totally synthetic drugs (e.g. dextromoramide, methadone,
pethidine) with similar properties. More recently, with the discovery of so-called
opioid receptors that bind all of these drugs, the term opioid has come to be used
as the collective description of the naturally occurring alkaloids, semisynthetic
derivatives and totally synthetic drugs. However, in general usage opiates and
opioids are often used interchangeably.
Effects
The outstanding property of opioid drugs is their ability to relieve pain. It was this
that inspired Thomas Sydenham in 1680 to say Among the remedies which it has
pleased Almighty God to relieve his suVerings, none is so universal and so
eYcacious as opium, and it is this property that continues to set opioids among
the most useful therapeutic agents available today.
96 Drugs of abuse and dependence
The analgesic action of opioids is probably due not only to their direct action at
one or more sites within the nervous system,
1
but also to the way in which they
make pain seem more tolerable. This in turn is related to the euphoriant eVect of
opioids their ability to induce a state of mental detachment and of extreme
well-being. However, in some individuals, some opioids induce not euphoria, but
the opposite mental state of dysphoria.
2,3
Opioids also have a sedative eVect on the nervous system causing inability to
concentrate, drowsiness and sleep. In addition they depress the respiratory centre,
the part of the brain that controls breathing, so that respiration becomes progress-
ively slower and more shallow. Higher doses cause respiratory arrest (breathing
stops), unconsciousness and death. Opioids also control cough by suppression of
the cough reXex.
1
A stimulant eVect on speciWc areas of the brain may cause nausea and vomiting
and also a very characteristic sign of opioid administration, the constricted, or
pin-point pupil of the eye (miosis). The action of opioids on the muscles of the
intestines causes constipation, accounting for their use in antidiarrhoeal prepara-
tions.
Tolerance
Tolerance develops to many, but not all, of the eVects of opioids so that increasing
doses have to be taken to obtain the desired eVect (of analgesia or euphoria, for
example). Ultimately a regular user may be consuming a daily dose of opioid
many times greater than that which would kill an opioid-naive individual. If drug
administration is interrupted in a regular user, by a period of imprisonment, for
example, tolerance is lost and if the old dose is suddenly resumed, it leads to
intoxication which may be fatal. Cross-tolerance occurs betweendiVerent opioids;
this means that theoretically it does not matter which opioid an addict takes. If he
or she cannot obtain the preferred opioid (usually heroin), a more easily available
one may be substituted.
Finally, it should be noted that tolerance does not usually develop to miosis
(pupil constriction) so that regular opioid users retain the characteristic, pin-
point pupils.
Physical dependence
Physical dependence on opioids develops if drug administration is regular and
continuous, but becomes apparent only if regular administration of the drug
ceases. While opioids are being taken there is no objective evidence of the existence
or the severity of physical dependence. If drug administration is interrupted, or if
other drugs that oppose the action of opioid (opioid antagonists) are given, the
symptoms and signs of the abstinence syndrome develop (Table 3.1). Its severity is
an indication of the degree of physical dependence that had developed.
Table 3.1. Opiate abstinence syndrome: symptoms and signs
Grade 0
Drug craving
Anxiety
Drug-seeking behaviour
Grade 1
Yawning
Sweating
Running eyes and nose
Restless sleep
Grade 2
Dilated pupils
GooseXesh (cold turkey)
Muscle twitching
Hot and cold Xushes; shivering
Aching bones and muscles
Loss of appetite
Irritability
Grade 3
Insomnia
Low-grade fever
Increased pulse rate
Increased respiratory rate
Increased blood pressure
Restlessness
Abdominal cramps
Nausea and vomiting
Diarrhoea
Weakness
Weight loss
97 Opioids
The severity of physical dependence depends on the particular opioid being
taken, the dose and the duration of chronic administration. As tolerance to
opioids develops, the daily dose is increased, and the severity of dependence
increases too. However, it reaches a maximum or ceiling for each drug, beyond
which further increases of dose have little eVect on the degree of physical depend-
ence as measured by the severity of the abstinence syndrome. Each opioid has its
own capacity to induce physical dependence; drugs such as codeine and dextrop-
ropoxyphene, even in very high dosage, do not cause physical dependence to
match that caused by morphine or heroin.
98 Drugs of abuse and dependence
Opioid abstinence syndrome
The signs and symptoms of opioid abstinence may be graded (Table 3.1) to
indicate the diVerent stages and the severity of the abstinence syndrome. This
grading is clinically convenient, if somewhat arbitrary, as the symptoms and signs
of any particular grade may not all be present simultaneously.
The severity and timing of the abstinence syndrome, its onset, peak and
duration of symptoms, all depend on a variety of factors, including which opioid
was being taken, its dose and for how long it had previously been taken. Generally,
an opioid with a short duration of action, such as heroin, has an abstinence
syndrome of earlier onset, shorter duration and greater intensity than a longer-
acting drug such as methadone. Similarly, the larger the dose of opioid, the more
intense the symptoms and signs of withdrawal. The personality of the addict, his
or her expectations and the ability to tolerate the discomfort of withdrawal are also
important.
The opioid abstinence syndrome, although extremely unpleasant, is rarely life
endangering in an otherwise healthy person. It is, however, very distressing for the
individual concerned who can think of nothing except an overwhelming and
urgent need for opioids. Consciousness is unimpaired so that the addict is
painfully aware of what is happening and feels generally so wretched that he or she
may say anything, whether true or not, in an attempt to receive earlier attendance
from a doctor and quicker relief of symptoms.
The abstinence syndrome can be immediately relieved by the administration of
any opioid; not necessarily the one that has been taken previously. Other sedative
drugs may provide partial symptomatic relief, but will not reverse the symptoms
and signs of the abstinence syndrome in the way that opioids do.
Psychological dependence
Psychological dependence on opioids is severe and accounts for the desire and
craving for drugs that eventually disrupt the addicts life, which may become
wholly devoted to obtaining more drugs. Unfortunately, psychological depend-
ence does not end when drug withdrawal has been achieved. It persists long after
the pain and discomfort of the abstinence syndrome have abated and accounts for
the high relapse rate of opioid addiction.
Opioid receptors
Although opiates, in one form or another, have been used by humans for
centuries, it is only during the last 25 years or so that considerable progress has
been made in understanding their mechanism of action. The Wrst step was the
discovery within the brain of opioid receptors.
4
These are specialized sites on the
cell membranes, with a very speciWc shape to which opioids bind. Drugs which Wt
99 Opioids
the receptor and activate it are called agonists. Other drugs, which bind to the
receptor but do not activate it, thereby preventing other opioids from binding to
it, are called antagonists. There appear to be three major categories of opioid
receptors, designated mu (), kappa () and delta (), with subtypes of each
category.
5
Each type of receptor is activated only by opioids conforming to its
particular shape and therefore has diVerent sensitivities to diVerent opioids and
develops selective tolerance to diVerent opioids. They are distributed diVerently
throughout the central and peripheral nervous systems, with the and receptors
concentrated in areas involved in the transmission and perception of pain and the
control of respiration.
That most important property of opioids the ability to induce analgesia
appears to be mediated by the supraspinal activation of receptors and by the
activation of receptors in the spinal cord. Other opioid eVects related to
receptor stimulation include euphoria, miosis, respiratory depression and reduced
gastrointestinal motility. In contrast, stimulation of receptors is often associated
with dysphoria. The eVects of stimulation have not yet been fully established but
all three types of receptor are found on presynaptic nerve terminals and have an
inhibitory eVect on transmission across synapses, by reducing the release of
neurotransmitters.
6
Opioid receptors have now been identiWed not only in humans but in all
vertebrates examined so far, as well as in some invertebrates. An obvious implica-
tion is the existence of naturally occurring (endogenous) opioid(s) in these
animals,
7,8
as it seems very unlikely that a receptor which is so widely distributed in
the Animal Kingdom should have as its only ligand a substance of plant origin. To
date, three distinct families of endogenous opioid peptides have been identiWed:
1 The enkephalins (Met- and Leu-enkephalin) which are composed of Wve amino
acids each, identical except for the Wfth amino acid;
2 Beta-endorphin with 31 amino acids;
3 Dynorphin with 17 amino acids.
They are coded by separate genes, occur in diVerent anatomical cell groups in the
brain and may have distinct biological functions. All three known classes of opioid
peptides are found in one or more sites that are known to be part of the bodys
intrinsic system for pain modulation under physiological conditions, and it
appears that endogenous opioids activate the receptors which modify trans-
mission in pain pathways.
1
What then of dependence on opioids? Do changes occur in this systemof opioid
transmitters and receptors to account for certain individuals becoming (or re-
maining) opioid abusers? So far, progress in this Weld has been limited, although
interesting: tolerance develops to endogenous opioids in vitro and in vivo
and cross-tolerance develops between morphine and endogenous opioids. An
100 Drugs of abuse and dependence
abstinence syndrome can be precipitated by the opioid antagonist, naloxone, in
rats dependent on endogenous opioids and, even more interesting, human beta-
endorphin, administered intravenously to opioid-dependent individuals produces
a marked improvement in the abstinence syndrome. Its beneWcial eVect on
diarrhoea, vomiting, tremor and restlessness lasts for several days, suggesting that
endogenous opioids may well be deWcient in the abstinence syndrome, their
production perhaps having been suppressed by the administration of opioid
drugs. Assays of endogenous opioids in dependent individuals have, however,
produced inconclusive results. This might be because the assays were done on
opioid peptides in blood, and it is unlikely that blood levels reXect levels in the
central nervous system. Furthermore, blood levels may be less important than
rates of biosynthesis and turnover.
Studies on opioid receptors have similarly been unhelpful as neither the numb-
er of receptors nor their properties (ability to bind opioids) seem to be altered in
the dependent state. However, it appears that chronic (agonist) action at or
receptors can cause tolerance and physical dependence within the neural systems
which are aVected by these receptors. Thus withdrawal of the agonist drug that
is, one which binds to and activates the receptor after a long period of
administration, or its displacement by a drug with antagonist properties, precipi-
tates a withdrawal syndrome which is quite speciWc for the receptor type.
receptor physical dependence, for example, produces severe withdrawal manifes-
tations with intense drug-seeking behaviour. There appears to be little cross-
tolerance between the diVerent receptors so that a drug with agonist properties
cannot suppress the withdrawal syndrome caused by a agonist withdrawal.
9
Different opioid drugs
There have been many attempts to separate, by means of chemical modiWcation,
the desirable analgesic action of opioids from their dependence-producing prop-
erty. Many new drugs have been synthesized either by changing the chemical
structure of naturally occurring opioids, or by synthesizing completely new drugs.
These are often introduced with extravagant claims that they do not cause
dependence. As their use becomes more widespread, however, their dependence-
producing potential usually becomes more obvious, and so far all of the clinically
useful opioid analgesics share similar structural characteristics and possess a
general similarity of action. Any diVerences between themtend to be diVerences of
degree rather than of nature.
In particular, it has been found that morphine and all the closely related
morphine-like opioid drugs have a high aYnity for the receptor (which was, in
fact, named for the drug morphine). They have less aYnity for and . Thus all
of these drugs can be described as agonist opioids, or as prototype agonists.
101 Opioids
Their low aYnity for receptors probably accounts for the fact that they rarely
cause hallucinations or dysphoria.
Morphine
Morphine is a naturally occurring opioid alkaloid. It was Wrst isolated in 1803 and
was named after Morpheus, the Greek god of sleep and dreams, because of its
sedative, sleep-inducing properties. Although it can be taken orally, the develop-
ment of the hypodermic syringe facilitated its widespread clinical use. It is still
frequently used in the management of severe pain, but suVers from the drawback
that it often causes nausea and vomiting. Perhaps for this reason it is not
particularly popular as an illicit drug of abuse or dependence.
Papaveretum(omnopon)
Papaveretumis a mixture of morphine and other opium alkaloids. It is often used
for preoperative medication, but is rarely abused, and then usually by members of
the medical profession.
Diamorphine (heroin)
Diamorphine was Wrst marketed as the heroic (or powerful) cure for morphin-
ism. It was claimed to be nonaddictive, but this soon proved to be untrue. Illicit
production occurs in large quantities in fairly primitive laboratories close to the
source of opium. This requires the chemical acetic anhydride and international
controls on the availability of this substance is one way of controlling illicit heroin
production. Once manufactured, heroin, in the form of a white powder, is much
easier to transport and smuggle than opium and is now available in most places in
the world, its source varying according to local and international politics (Appen-
dix 1).
Heroin is a more potent analgesic than morphine, and is used medicinally in a
dose of 510 mg 4 hourly. It is less likely to cause nausea or constipation and has a
much greater euphoric eVect. Perhaps for these reasons it is the drug of choice of
most opioid-dependent individuals. It may be taken orally or administered by
intramuscular, intravenous (mainlining) or subcutaneous (skin-popping) injec-
tion. A popular way of taking it is called chasing the dragon, in which the heroin
is heated on a piece of foil and the resultant fumes are inhaled. This method,
although just as likely to cause dependence, is safer than injecting, which is
associated with a number of serious complications. Because chasing the dragon is
easier and safer than injecting, it may encourage those who would not have dared
to inject, to experiment with heroin and subsequently become addicted. In time,
as the individuals habit becomes larger and therefore more expensive to maintain,
or if heroin is in short supply (and again more expensive), it is more likely to be
102 Drugs of abuse and dependence
taken by intravenous injection. This delivers all the available drug right into the
bloodstream providing the addict with the best kick (high, rush) possible for
that dose of heroin.
Methadone (physeptone)
Methadone is a synthetic opioid analgesic with a long duration of action (about 24
hours) so that once daily administration to an opioid-dependent individual is
suYcient to prevent the onset of the abstinence syndrome. For this reason it is the
opioid most frequently prescribed in the treatment of opioid dependence. Al-
though also available in tablet or injectable form, it is usually prescribed as
methadone mixture which is unsuitable for injection and has little black market
value. Most addicts receive between 30 and 80 mg methadone daily. Despite
cross-tolerance betweenthe diVerent opioids, opioid-dependent individuals claim
to be able to tell the diVerence between heroin (their drug of choice) and
methadone, which does not give them the euphoric high that they seek. In
addition, methadone often causes increased sweating, a side eVect which does not
seem to occur with other opioids and for which there is no physiological explana-
tion.
Although methadone is a potent analgesic it is rarely prescribed for this
purpose.
L-alpha acetylmethadol (LAAM)
LAAM is a derivative of methadone and was initially developed as an analgesic.
Although it has been available since 1993, it has only recently been licensed in the
UK for the treatment of opioid dependence. It is very long-acting and can prevent
opioid withdrawal symptoms for more than 72 hours. Hence, as an alternative to
methadone, it requires only three times weekly administration. However, the
onset of action is much slower than with methadone and the time taken to reach
maintenance levels is correspondingly longer (820 days, compared with 58 days
for methadone). It is reputed to have less euphoriant eVect and, because it is
metabolized more slowly, it produces a long, even plateau in blood levels. The
danger of overdose is increased due to cumulative toxicity if illicit opioids are used
and the treatment of opioid-dependent individuals with LAAM should always be
under the supervision of a specialist.
10
Pethidine (Pethilorfan, Pamergan; meperidine, Demerol in USA)
Pethidine is a synthetic opioid widely used clinically as an analgesic in childbirth
and postoperatively. It is a frequent drug of abuse for opioid-dependent individ-
uals in the medical or related professions.
103 Opioids
Dipipanone (with cyclizine as Diconal); dextromoramide (Palfium)
These are two synthetic opioid drugs which, during the late 1970s and early 1980s,
were very popular with opioid-dependent individuals in the UK.
11
They were
often prescribed by independent doctors whom the addicts consulted because the
drug dependence treatment units (DDTUs) were (and are) unwilling to prescribe
the injectable opioids which the addicts sought. Although intended for oral use,
Diconal tablets were often crushed, dispersed in water and injected, resulting in
the expected complications of self-injection. Tablets surplus to requirement were
sold on the black market. Because of the increasing frequency of dependence on
dipipanone, it was brought under the same control as heroin and cocaine, so that
only doctors with a licence from the Home OYce may now prescribe dipipanone
to addicts. More recently, because illicit heroin is widely available on the black
market, dextromoramide and dipipanone have become less attractive to addicts.
Dextropropoxyphene (Doloxene)
Dextropropoxyphene is a mild opioid analgesic derived from methadone, but
with less addictive and analgesic potential. Although available in capsule form, it is
much more popularly combined with paracetamol as Distalgesic. Abuse of Distal-
gesic is not uncommon and overdose is particularly serious, because of the
combination of hepatotoxicity due to paracetamol and respiratory depression due
to dextropropoxyphene.
Codeine
Codeine is another alkaloid found in crude opium. It is a much less eVective
analgesic than morphine and is therefore used for the relief of mild to moderate
pain only; it is often combined with aspirin or paracetamol. Its constipating eVect
is utilized in the treatment of diarrhoea and it is also used as a cough suppressant.
It must not be forgotten, however, that codeine and its derivatives (pholcodine,
dihydrocodeine) are opioids with a liability for abuse and dependence, albeit less
than that of morphine or heroin. As some of these preparations (e.g. codeine
phosphate and pholcodine syrups and linctuses) are available without prescrip-
tion, over the counter, opioid addicts can buy them easily. They sometimes use
them to supplement supplies from other sources or to prevent the onset of the
opioid abstinence syndrome.
Opioid antagonists and agonist-antagonists
During the search for eVective opioid analgesics free from the dependence liability
of morphine and heroin, new drugs have been identiWed which are devoid of
analgesic properties, and which oppose or antagonize the respiratory depressant
104 Drugs of abuse and dependence
eVects of opioids. These drugs (e.g. naloxone, naltrexone) are known as opioid
antagonists.
It is now understood that their properties arise because they bind to opioid
receptors but do not activate them. For example, naloxone is a receptor
antagonist which also binds to a lesser degree to and receptors. It antagonizes
the eVect of morphine and related drugs by displacing them from their receptor
sites. However, binding to receptors and activating them is not an all or none
phenomenon. Some drugs, described as partial agonists, may bind to a receptor
but not activate it fully. In so doing they may displace a full agonist, thus reducing
or antagonizing its eVects. Thus partial agonists are commonly described as
agonist-antagonists and, unlike the full agonists, their eVects do not increase in
proportion to the dose administered, but appear to have a ceiling. It is also
important to appreciate that as well as having diVerent aYnities for the diVerent
receptor sites, a particular drug may be a full agonist at one receptor and an
antagonist or partial agonist at another.
Because classical opioid dependence appears to be so Wrmly linked to receptor
activity, it seems likely that a partial agonist might have less abuse and depend-
ence liability than the prototype agonists. Much recent research has therefore
concentrated on the mode of action of diVerent drugs at the diVerent receptor
sites and a number of agonist-antagonist opioids are now available. However, the
abuse liability of a particular drug is more than the mathematical sum of its
activity at several receptor sites. Other factors, such as its solubility, the ease with
which it enters the nervous system and the Wrmness with which it binds to the
receptor site may all be important. Unfortunately, there is no single animal species
which can provide a completely reliable model for predicting the abuse and
dependence liability of opioid drugs and these problems usually become apparent
only when the drug has become widely available for use by humans outside the
laboratory setting.
Pentazocine (Fortral)
Pentazocine is a partial agonist with agonist activity at receptors too. It may
precipitate withdrawal symptoms in opioid-dependent individuals. When admin-
istered by injection it is a more potent analgesic than codeine or dihydrocodeine,
but it sometimes causes hallucinations and thought disturbance, presumably
because of receptor activation. High doses may also cause respiratory depress-
ion, raised blood pressure and tachycardia.
Some of the psychotomimetic eVects of pentazocine are not blocked by
naloxone, suggesting that it also aVects other receptor sites within the brain. Two
such receptors are the phencyclidine receptor site and a receptor which also binds
to dopaminergic drugs. This interaction of pentazocine with both opioid and
105 Opioids
nonopioid receptors perhaps accounts for the range of side eVects associated with
its use.
Although the dependence liability of pentazocine is less than that of morphine
or heroin, cases of abuse and dependence have been reported and in certain places
abuse became widespread. In some places in the USA, for example, pentazocine
abusers used to add crushed tablets of the antihistamine tripelennamine, which is
known to enhance the reinforcing and analgesic eVects of pentazocine, to crushed
tablets of pentazocine and inject this mixture, known as Ts and blues, sub-
cutaneously or intravenously. The eVect was said to be indistinguishable from the
rush or high caused by heroin and lasted 510 minutes; this practice has become
less common. Repeated injection of this mixture may cause convulsions. How-
ever, the non- actions of pentazocine at other receptors, which cause progressive
increases in dysphoria and other undesirable subjective eVects, tend to limit its
abuse potential.
Self-injection with pentazocine causes characteristic Wbrotic changes in the skin
and muscle.
Buprenorphine (Temgesic, Subutex)
Buprenorphine is a partial receptor agonist with a long duration of action
because of tight receptor binding. It is an eVective analgesic which is administered
sublingually (under the tongue) or by injection. Oral administration is unsatisfac-
tory because the drug is metabolized very rapidly by the liver.
An unusual property of buprenorphine is that, after chronic administration, the
onset of the abstinence syndrome is delayed. There are few, if any, signs of
withdrawal during the Wrst 48 hours and only mild signs from the 3rd to the 10th
day. In one study, more marked withdrawal eVects were reported on the 14th day.
Heroin addicts dependent on a small dose of opioid can be transferred on to
buprenorphine, which can be withdrawn fairly easily because of the delayed onset
of the abstinence syndrome. While they are taking buprenorphine, the subjective
eVects of self-administered heroin are reduced, presumably because buprenor-
phine is acting as an antagonist on the receptors.
12,13
Thus theoretically the
rewarding properties of heroin are impaired and the likelihood of future adminis-
tration should be reduced. However, if buprenorphine is given to individuals
dependent on large doses of opioids, its antagonist properties precipitate the onset
of withdrawal symptoms. Despite early optimism, the abuse potential of bup-
renorphine is causing concern. Opioid addicts are clearly able to identify
buprenorphine as an opioid when it is administered in suYcient quantity (0.8
2.0 mg) and there are reports of abuse and dependence from several countries.
Tablets intended for sublingual administration are being crushed and injected by
addicts.
106 Drugs of abuse and dependence
It is interesting that naloxone in doses of up to 4 mg does not precipitate the
buprenorphine withdrawal syndrome, although higher doses can reverse the
eVects of buprenorphine and should theoretically precipitate withdrawal in de-
pendent individuals.
Buprenorphine has recently been licensed in the UK for the treatment of opioid
addiction but has been used more extensively in France over the last few years as
substitution therapy for opioid addiction. The doses are very much higher than for
analgesia, an average dose for an opioid addict being in the range of 812 mg
daily.
14
Butorphanol
Butorphanol is an agonist-antagonist opioid with aYnity to and receptors.
Like other agonists it has analgesic and respiratory depressant properties and
like other agonists it can cause psychotomimetic symptoms. It can precipitate
symptoms of withdrawal when administered to morphine-dependent individuals.
Although butorphanol has positive reinforcing properties in animals, there have
been only occasional reports of dependence upon it. This is probably because, like
pentazocine, it tends to produce undesirable subjective eVects, rather than the
sought-after euphoria induced by morphine and other prototype agonists.
Nalbuphine (Nubain)
Like pentazocine, nalbuphine is a partial agonist with a high aYnity for
receptors but it is less likely than pentazocine to cause dysphoric symptoms. It can
reverse the respiratory depression caused by full agonists and precipitates the
withdrawal syndrome if given to individuals dependent on these drugs. Experi-
enced morphine users usually recognize nalbuphine as morphine-like, and after a
period of chronic administration of nalbuphine, naloxone precipitates a mild
withdrawal syndrome. So far, however, there have been very few cases of abuse.
The drugs mentioned in this section do not forma comprehensive list of opioid
analgesics. They were selected because they are common, or fairly common, drugs
of abuse or dependence, or because they are used to treat opioid dependence.
Other opioids are available and may more rarely be the subject of abuse; depend-
ence upon them is similar to that described in this section.
Sedative hypnotics
Sedative hypnotic drugs can be conveniently classiWed into two groups:
1 The barbiturates, which dominated this area of therapeutics for half a century;
2 The more modern nonbarbiturates which were developed because of all the
disadvantages and dangers of the earlier drugs.
107 Sedative hypnotics
Since the 1960s the benzodiazepine nonbarbiturates have been of overwhelming
importance in terms of the number of prescriptions issued and the number of
individuals receiving these drugs. However, both barbiturate and nonbarbiturate
sedative hypnotic drugs have many similar pharmacological properties.
Effects
Sedative hypnotic drugs have a depressant eVect on the brain. In small doses they
relieve anxiety, inducing a sense of relaxation. In a slightly larger dose they cause
drowsiness and sleep, shortening the time until its onset and prolonging its
duration. Even when taken in small, hypnotic doses, these drugs have a hang-
over eVect the following day, often leaving the patient feeling drugged and
drowsy. Slowing of performance occurs, measurable under laboratory conditions
and manifesting itself in daily life by an inability to concentrate, to make quick
decisions or to carry out tasks as quickly and eYciently as usual. Driving a car or
operating machinery after taking them the night before may therefore be hazard-
ous.
In excessive doses, such as those taken in deliberate self-poisoning, sedative
hypnotic drugs cause a prolonged deep coma with respiratory depression (slow,
shallow breathing) and low blood pressure. Death, due to respiratory failure, may
occur quite suddenly and unexpectedly with barbiturates, although an overdose of
a benzodiazepine alone is unlikely to be fatal.
Tolerance
Tolerance develops rapidly to some of the eVects of sedative hypnotics drugs. After
taking themfor a fewdays or weeks, the patient is again taking longer to go to sleep
and the duration of sleep returns to normal. To achieve the original and desired
improvement in sleep the dose has to be increased. After a while the habitual user
may show little sign of sedation and may be sleeping for only an hour or two more
than usual on a night-time dose that would be profoundly sedating for anyone not
used to taking these drugs.
Tolerance also develops to the anxiolytic eVect of these drugs, so that they
rapidly become ineVective if prescribed in a normal, therapeutic dosage. It is
dangerous to increase the dose, however, because this increases the risk and the
severity of physical dependence.
Physical dependence
Physical dependence on sedative hypnotics drugs is characterized by the manifes-
tations of the abstinence syndrome, and by a state of chronic intoxication which
develops in those who habitually take very large doses.
It is diYcult to be precise about the dose or the duration of consumption of
108 Drugs of abuse and dependence
these drugs necessary to cause physical dependence, because it varies according to
the criteria of dependence that are adopted. For example, withdrawal of thera-
peutic doses of benzodiazepines given for only a few weeks may lead to anxiety,
depression, tremor and somatic symptoms. Because these are often similar to the
symptoms of the original illness, it used to be thought that they were evidence that
treatment should be continued for longer. Now, however, it is appreciated that
they are genuine symptoms of withdrawal (rebound) and that during this stage,
anxiety may increase to an intensity above that in the predrug period. This type of
rebound phenomenon is particularly marked in patients stopping medium-acting
benzodiazepines, such as lorazepam, and the importance of prescribing these
drugs for short periods only (24 weeks) is stressed. Another form of rebound
anxiety occurs, particularly with shorter-acting compounds, when there may be
interdose anxiety associated with falling blood levels as the time for the next dose
approaches.
Similarly, withdrawal of the normal hypnotic dose of sedative hypnotics drugs
may precipitate nightmares, broken sleep with vivid dreams and increased REM
(rapid eye movements) which may persist for several weeks. This is known as
rebound insomnia and its appearance following the abrupt withdrawal of benzo-
diazepine hypnotics suggests that even modest doses can cause mild physical
dependence. Higher doses (say diazepam 60 mg daily) taken over a period of 12
months would be suYcient to cause noticeable physical dependence with many of
the signs listed below, although there is considerable individual variability of
response and some people may be vulnerable to severe consequences of with-
drawal, having taken a much smaller dose.
Sedative hypnotics abstinence syndrome
The symptoms and signs of sedative hypnotic withdrawal develop progressively.
They include weakness, anxiety, tremor, dizziness, insomnia, impaired concentra-
tion, loss of appetite, nausea and vomiting, dysphoria, headaches, incoordination,
heightened sensory perception, lethargy, depersonalization, tiredness, blurred
vision, facial burning sensation, hot and cold feelings with sweating and muscle
aching. All of these symptoms may be experienced when patients are withdrawn
from long-term treatment (3 months) with a benzodiazepine administered in
normal dosage.
1517
Perceptual symptoms vary considerably from patient to pa-
tient and can be very distressing. It should be emphasized that these symptoms are
genuine manifestations of withdrawal and are not a resurgence of the original
condition for which the sedatives were originally prescribed; thus patients who
were prescribed benzodiazepines for nonpsychiatric reasons may experience per-
ceptual symptoms, anxiety and insomnia when their medication is stopped. The
abstinence syndrome usually begins within 2 days of drug withdrawal although it
109 Sedative hypnotics
may be delayed for over a week; it may occur despite dose tapering, but usually
subsides over a period of a few weeks.
If larger doses of sedative hypnotics have been taken, withdrawal will lead to an
increased pulse rate (more than 100/min) with a further increase (of more than
15/min) on standing. Standing is also associated with a fall in blood pressure.
There is muscle twitching and tremor, increased reXexes and dilated pupils. These
unpleasant, but not particularly dangerous symptoms may, however, be followed
by grand mal convulsions (Wts) which may progress to life-threatening status
epilepticus, in which the patient has Wts continuously. A psychotic state, resembl-
ing alcoholic delirium tremens in which the patient is very agitated and confused
and suVers auditory and visual hallucinations may also occur.
Although the sedative hypnotic withdrawal syndrome is the same in its broad
outline regardless of which class of drug is responsible, there are diVerences
between diVerent drugs. Fits and delirium are more common after barbiturate
withdrawal, while milder symptoms such as anorexia, agitation and insomnia are
more common after benzodiazepine withdrawal.
18
Chronic intoxication
Because there is an upper limit to tolerance to sedative hypnotic drugs and because
dependent individuals often increase their daily consumption beyond this point,
chronic intoxication is a common feature of their condition. This resembles
intoxication with alcohol and is characterized by diYculty in thinking, slow and
slurred speech, poor comprehension and memory, and emotional lability. Irrita-
bility and moroseness are common. It is interesting that abusers seemless aware of
their mood changes and behavioural impairment when taking high doses of
benzodiazepines than with high doses of barbiturates.
Chronic intoxication with barbiturates, which is now less common than form-
erly, is accompanied by neurological symptoms and signs: nystagmus (jerky,
involuntary movements of the eyes), double vision, squint, diYculty in visual
accommodation, unsteadiness and falling. With larger doses the increasing seda-
tion leads to the subject falling, sleep and eventually respiratory depression and
death. In fact, one of the main risks of chronic barbiturate use and the consequent
development of tolerance is that the gap between the intoxicating dose and the
fatal dose is dangerously reduced.
Psychological dependence
Psychological dependence on sedative hypnotic drugs is manifested by craving for
the drug and by drug-seeking behaviour. Animals will performan action repeated-
ly to obtain these drugs, thereby demonstrating their reinforcing properties.
However, sedative hypnotics are less powerful reinforcers of behaviour than are
110 Drugs of abuse and dependence
opioids or cocaine, and undoubtedly cause less severe psychological dependence.
Although psychological dependence on barbiturates has long been recognized,
it was thought at Wrst that benzodiazepines were free from this disadvantage.
However, the considerable diYculty experienced by many benzodiazepine users in
managing without their drugs, even when they were withdrawn gradually to
prevent the onset of physical symptoms, has contradicted early beliefs and hopes.
It is nowrecognized that benzodiazepines can and do cause psychological depend-
ence and that this is closely related to the dose that is taken and the duration of
administration.
19
For this reason the indications for prescribing them are now
deWned very strictly, and it is recommended that they should be prescribed in the
smallest eVective dose for a period that does not usually exceed 4 weeks.
Different sedative hypnotic drugs
Barbiturates
Barbiturate drugs are all derived from a single chemical substance, barbituric acid.
The Wrst to be synthesized was barbitone (Veronal) which was introduced into
clinical practice in 1903 when it was welcomed as the solution to one of mans
oldest and most intractable problems insomnia.
Over the years many diVerent barbiturates have been synthesized. Some very
short-acting barbiturates are administered intravenously for the induction of
general anaesthesia (e.g. thiopentone, methohexitone). Other, long-acting com-
pounds such as phenobarbitone and methylphenobarbitone are used to treat
epilepsy. Neither of these two types of barbiturates have been involved in prob-
lems of abuse and dependence and concern has centred on barbiturates of
medium duration of action which used to be prescribed for the treatment of
anxiety or insomnia. These include amylobarbitone, butobarbitone, pentobarbi-
tone and quinalbarbitone. The similarities between all of these drugs are more
striking than their diVerences.
Nonbarbiturate, nonbenzodiazepine sedative hypnotics
Because of the disadvantages and dangers of barbiturates and particularly their
dependence liability and their serious eVects when taken in overdose, many
attempts were made to synthesize safer sedative hypnotics. These include drugs
such as meprobamate (Equanil), glutethimide (Doriden), dichloralphenazone
(Welldorm) and methaqualone which, when they were introduced, were hailed,
like the barbiturates before them, as an answer to the prayer for a safe hypnotic.
Clinical experience, however, revealed that their eVects on the nervous system are
similar to those of barbiturates, that tolerance develops together with physical and
psychological dependence. When taken in overdose all of these drugs show
features of poisoning similar to those of barbiturate overdose although some, such
as glutethimide, which is no longer marketed in the UK, are particularly danger-
111 Sedative hypnotics
ous. Methaqualone used to be available in combination with an antihistamine
(Mandrax) and became a very common drug of abuse. None of these drugs is
important therapeutically now.
Benzodiazepines
Because the above drugs were no more satisfactory than barbiturates, the search
continued for safer and better alternatives. The benzodiazepines were introduced
into clinical practice in the 1960s and an enormous number have now been
synthesized. Like barbiturates they possess powerful antiepileptic properties, al-
though they are rarely used in the long-term treatment of epilepsy because their
eVectiveness wanes within a few months. However, a benzodiazepine (diazepam
or clonazepam) is the drug of choice for the emergency treatment of the life-
threatening condition of major status epilepticus. In addition, benzodiazepines
have muscle relaxant properties permitting their use for the relief of muscle spasm
or spasticity. They diVer fromearlier sedative hypnotics drugs in being much safer
when taken in overdose. Indeed, very large doses of benzodiazepines rarely cause
suYcient respiratory depression to kill the patient unless another drug or alcohol
has been taken simultaneously. Their safety in overdose is a very important
property in societies where deliberate self-poisoning with psychoactive drugs has
become very common.
The main advantage of benzodiazepines over older drugs in this class is their
ability, in low doses, to relieve anxiety without causing undue sedation. This was
undoubtedly the basis for their early popularity, when their potential for produc-
ing dependence was not appreciated, and a vast range of benzodiazepines were
synthesized. Their similarities are more striking than their diVerences, which
mostly depend on their duration of action. The early benzodiazepines (e.g.
diazepam, chlordiazepoxide) are long-acting drugs, mainly because they are
converted in the body to active metabolites such as desmethyldiazepam which
itself has a half-life of 72 hours or more. These drugs have the disadvantage that
they often cause a prolonged hangover, leaving the patient feeling drugged for
some time. For this reason, shorter-acting benzodiazepines (e.g. lorazepam,
oxazepam) were developed, which bypass desmethyldiazepam in their metabolic
pathways and which are more suitable as daytime anxiolytics and as hypnotics
with minimal hangover.
19
However, these short-acting drugs cause rapid rises and
falls in blood levels so that withdrawal phenomena are more common and patients
may crave the next tablet to relieve their distressing symptoms. Dependence on
them often seems more severe and more diYcult to treat than dependence on
benzodiazepines with a longer duration of action,
20
although there is insuYcient
scientiWc evidence that a particular benzodiazepine is any better or worse than any
other, in terms of therapeutic eVectiveness or dependence liability.
21
112 Drugs of abuse and dependence
Flunitrazepam(Rohypnol)
Flunitrazepam has recently emerged as a drug of abuse that is giving rise to
particular concern. It is a potent sedative hypnotic which gives an increased feeling
of power and self-esteem, leading to a belief that everything is possible. It may be
associated with loss of episodic memory and impulsive violence, particularly when
taken with alcohol. It is often used as a cheap way of becoming intoxicated.
22
Flunitrazepamhas gained notoriety as the date rape drug, with men accused of
slipping it into the alcoholic drink of unsuspecting women victims and then
sexually abusing them. The drug is colourless, odourless and tasteless and leads to
drowsiness, impaired motor skills and, importantly, anterograde amnesia. This
makes it diYcult to obtain accurate information about the alleged sexual abuse. It
is therefore recommended that if a woman who appears intoxicated complains of
sexual abuse, a urine specimen should be analysed for Xunitrazepam.
23,24
Cross-tolerance
It is not surprising that cross-tolerance develops between diVerent barbiturates
and that any barbiturate can be taken to prevent or treat the abstinence syndrome
caused by withdrawal of another. It is perhaps less expected that a considerable
degree of cross-tolerance also exists with other central nervous system depressants
such as alcohol, benzodiazepines and other nonbarbiturate hypnotics including
chlormethiazole. The existence of this cross-tolerance emphasizes the intrinsic
similarities of all of these drugs, whatever their diVerences in terms of chemical
structure, etc.
19,25
The discovery of separate benzodiazepine receptors in human brain tissues may
go some way towards explaining the diVerences that do exist. These receptors are
associated with the receptor sites for the neuroinhibitor -aminobutyric acid
(GABA) and benzodiazepines appear to act by promoting the depressant eVect of
GABA on the brain, thus inducing sedation and sleep. It is interesting that the
benzodiazepine receptor is just one component of a large, macromolecular struc-
ture which has binding sites not only for benzodiazepines but also for barbiturates
and GABA and that all three receptor sites appear to inXuence channels in the cell
membrane for chloride ions. In particular, benzodiazepines increase the frequency
of GABA-induced opening of the chloride channels and, in the absence of GABA,
they are ineVective. Both benzodiazepines and sedative barbiturates increase
GABA binding an observation that may underpin some of their clinical similari-
ties.
The eVects of benzodiazepines in relieving anxiety and in blocking seizure
activity is correlated with their aYnity for receptor sites and, in the light of
knowledge gained from the study of opioid receptor sites, it is not surprising that
benzodiazepine antagonists have been identiWed, such as Xumazenil, that compete
113 Stimulant drugs
with agonist drugs by occupying the receptor sites and blocking their action.
Partial agonists have also beenidentiWed, that occupy the receptors but have only a
limited action, as well as inverse agonists, which have opposite eVects on the
receptors to those induced by benzodiazepines and can cause seizures and
anxiety.
26
There are two subtypes of benzodiazepine receptor (BZD
1
and BZD
2
, or omega
1
and omega
2
) which are widely but diVerentially distributed throughout the central
nervous system, with high densities in the cerebral cortex, the limbic system and
the cerebellum. In addition peripheral-type receptors have been identiWed both
in nonneural tissue as well as the central nervous system.
Stimulant drugs
Amphetamine
Amphetamine is the general name given to a class of synthetic drugs that are
similar in eVect to a substance produced by the body called adrenalin. Adrenalin
acts as a transmitter in part of the nervous system known as the sympathetic
nervous system, which prepares the body for Wght or Xight, releasing sugars
stored in the liver and increasing heart and respiration rates. Amphetamines,
because they mimic many of the eVects of adrenalin, are known as sympath-
omimetic amines. They appear to act by releasing the neurotransmitters nor-
adrenalin and dopamine, by inhibiting their reuptake and perhaps also by a direct
agonist action on the receptor sites for these two chemicals. There is extensive
illicit manufacture of amphetamine and methamphetamine (Appendix 1).
The least potent of the amphetamines is amphetamine sulphate, which was
marketed in 1932 as a nasal decongestant in the formof an inhaler (Benzedrine). It
was soon realized that one of the side eVects of Benzedrine was sleeplessness and it
was thus that the stimulant eVect of amphetamine was revealed.
Amphetamine sulphate is in fact a mixture of two forms of amphetamine,
chemically indistinguishable and diVering only in the direction in which they
rotate plane polarized light. Dextrorotatory amphetamine (d-amphetamine) is
approximately twice as powerful a central stimulant as the racemic compound
which contains both forms of amphetamine, and three to four times as potent as
laevorotatory amphetamine (l-amphetamine).
27
Effects
Amphetamine is a powerful central stimulant producing an elevated mood and
making the user feel energetic, alert and self-conWdent.
28
Task performance that
has been impaired by boredom or fatigue is improved, accounting for the popu-
larity of amphetamine among students working for examinations. Feelings of
114 Drugs of abuse and dependence
hunger and fatigue are reduced and there is increased talkativeness, restlessness
and sometimes agitation. Some individuals may, however, become anxious and
irritable.
29
Because it is a sympathomimetic drug, amphetamine causes increased
heart rate and blood pressure, palpitations, dilated pupils, dry mouth and sweat-
ing; l-amphetamine has a greater eVect on the cardiovascular system than
d-amphetamine.
Acute intoxication with amphetamine is characterized by dizziness, sweating,
chest pain, palpitations, hypertension and cardiac arrhythmias. Body temperature
may be raised and convulsions often occur.
Tolerance
Tolerance develops to some but not all of the eVects of amphetamine. Those
taking it for its euphoric, mood-elevating eVect Wnd that they have to escalate the
dose progressively to maintain this eVect and may take 2501000 mg daily.
However, because they have also become tolerant to its cardiovascular eVects they
do not suVer from adverse side eVects. Because tolerance also develops to the
appetite-suppressant eVect of amphetamine, it is not eVective in the treatment of
obesity. It is, however, useful in the treatment of narcolepsy, a rare condition in
which the suVerer keeps falling asleep suddenly and inappropriately; tolerance
does not develop to the awakening eVect of amphetamine and narcolepsy remains
one of the few therapeutic indications for amphetamine (1060 mg daily). Am-
phetamine and its derivatives have a paradoxical eVect on hyperkinetic children,
reducing their antisocial behaviour and increasing their attention span. As toler-
ance does not develop to these eVects, amphetamine is sometimes used in the
management of this condition,
27
although the eVect of long-term treatment is not
clear.
In addition to the development of tolerance, amphetamine can also produce
sensitization, which is sometimes called reverse tolerance. It has been observed in
animals, when single daily doses of the drug that do not, at Wrst, cause hyperactiv-
ity or stereotyped behaviour, can start to induce this behaviour if injections
continue over a period of several weeks. This eVect is believed to be mediated by
the release of dopamine in the striatum (part of the mid-brain) and it has been
suggested that this is the basis of the stereotyped behaviour that is sometimes
observed in amphetamine and cocaine addicts.
Cross-tolerance develops between diVerent amphetamines, but not between
amphetamine and cocaine, despite their many similarities.
Physical dependence
Although chronic amphetamine users may escalate their dose until they are taking
large quantities, the existence of physical dependence is disputed. After long-term
115 Stimulant drugs
use, or after a binge of drug-taking lasting a few days, abrupt withdrawal is
commonly followed by feelings of fatigue, depression and hunger, and a need for
sleep (the crash). Although these may be the manifestations of a withdrawal
syndrome it has been suggested that they are the normal reaction to the lack of
sleep and food that occurs with chronic amphetamine use.
30
Depression at this
time may be so severe that suicide is a real risk.
Psychological dependence
Psychological dependence on amphetamine undoubtedly develops and chronic
users experience intense craving and exhibit drug-seeking behaviour. This craving
may last, with varying intensity, for several weeks, responding to emotions and to
drug-related stimuli. Laboratory experiments on animals conWrm that ampheta-
mine has powerful reinforcing properties.
Adverse effects
The most serious consequence of amphetamine abuse is a psychotic illness, which
may be diYcult to distinguish from schizophrenia. It is characterized by paranoid
delusions and by auditory and visual hallucinations. It usually develops if am-
phetamine has been taken for a long time and the dose has been escalated. It is
particularly common if methylamphetamine is injected, but can occur with oral
use and may even develop after a single, oral dose of amphetamine. The symptoms
usually remit within 1 week of drug withdrawal.
Another complication of chronic amphetamine abuse is automatic, stereotyped
behaviour in which some action such as tidying a handbag, Wddling with a radio or
touching/picking at the skin on the face or extremities may continue for hours at a
time. Scratching or picking at the skin is often associated with tactile hallucina-
tions and with delusions of being infested with parasitic insects.
Amphetamine-type stimulants
Since the introduction of amphetamine into medical practice many other drugs
have been synthesized for their stimulant or appetite-suppressant eVects. Methyl-
amphetamine, an injectable amphetamine, was available in the 1960s, but was
withdrawn from retail pharmacies when there was a veritable epidemic of intra-
venous methylamphetamine abuse, with many cases of psychosis. Benzphetamine
was used for the treatment of obesity because of its appetite-suppressant proper-
ties, but problems of dependence soon became apparent. Since then a range of
drugs have been produced. Most are chemically similar to amphetamine, have
rapidly become drugs of abuse and have been brought under strict control. They
include methylphenidate (Ritalin), phenmetrazine (Preludin), diethylpropion
(Apisate), phentermine (Duramin) and mazindol (Teronac). Slight modiWcations
116 Drugs of abuse and dependence
of chemical structure have produced drugs such as fenXuramine and chlorphen-
termine with less stimulant properties, but their role in the long-term manage-
ment of obesity remains questionable.
Methylphenidate
Methylphenidate warrants special mention because of the recent upsurge in its
prescription. This is reXected by the increase in its global (licit) manufacture from
2.8 tonnes in 1990 to 15.3 tonnes in 1997. This is predominantly due to increased
consumption in the USA, which accounts for about 85% of total world produc-
tion, but the same pattern is occurring in other countries too. For example,
manufacture and importation for consumption has increased in Spain (484%),
UK (277%), New Zealand (107%) and The Netherlands (64%).
31
This growth is because methylphenidate is increasingly being prescribed in the
treatment of attention-deWcit disorder (ADD) and its variant, attention-deWcit
hyperactivity disorder (ADHD). These are now the most commonly diagnosed
childhood behaviour disorders occurring most frequently in boys, aged 614 years
and characterized by inattention, impulsivity and sometimes hyperactivity. There
is evidence that methylphenidate is eVective at reducing these symptoms in the
short term, while children continue to take medication. However, because of the
diYculty of separating this condition from unacceptable/undesirable behaviour
due to underlying social problems, there is growing concern that methylphenidate
is now being used as a pharmacological solution to complex and diYcult underly-
ing relationship and parenting problems. These concerns are heightened by
inexplicable diVerences between diVerent physicians in their rates of prescribing.
For example, in some schools up to 20% of children may be receiving methyl-
phenidate, while in others none do. This is particularly worrying when the
long-term eVects of psychotropic drugs on children are not known. In addition,
with such a large pool of legitimate methylphenidate available, it is not surprising
that some Wnds its way into the illicit market, with some adolescents purchasing or
stealing tablets from those who have them on prescription. Methylphenidate
tablets may then be crushed and snorted.
32
In response to growing concern in the UK both about the increased prescrip-
tion rate and about equity of access to treatment guidance on the use of
methylphenidate for ADHD has been issued by the National Institute for Clinical
Excellence. This states that treatment should only be initiated by child and
adolescent paediatricians or psychiatrists with expertise in ADHD, and that,
ideally, it should be part of a wider, comprehensive treatment programme involv-
ing advice and support to parents and teachers. Children receiving treatment
should be monitored regularly, and the need for continued therapy should be
carefully assessed under specialist supervision.
33
It is to be hoped that these
117 Stimulant drugs
measures will ensure that methylphenidate prescription is restricted to genuine
cases of ADHD and that leakage to the illicit market is minimized.
Pemoline
Pemoline is an amphetamine-like drug which decreases appetite and has central
stimulant eVects. Its therapeutic usefulness is rated as lowand in large doses it may
produce hyperactivity, dyskinesia, seizures, insomnia and hallucinations.
The euphoric eVects induced by pemoline are signiWcantly less than those of
amphetamine and its reinforcing properties appear very limited. In addition, it is
not soluble in water so that there is less likelihood of it being injected. It is perhaps
not surprising therefore that there have been few case reports of dependence on
pemoline, although large quantities are diverted illicitly, mainly to countries in
West Africa. Abuse has been reported from several countries and pemoline has
been suspected in some cases of drug abuse by athletes and in the doping of
racehorses.
Cocaine
Cocaine is an alkaloid prepared from the leaves of the coca bush Erythroxylum
coca, which grows in the mountainous regions of Central and South America
(Colombia, Bolivia, Peru). Traditionally, the leaves were (and are) chewed by the
natives apparently without ill eVect to alleviate fatigue, hunger and cold. They
were used by the Incas in religious ceremonies as well as socially and for medicinal
purposes.
Cocaine itself was Wrst isolated in the 1880s and its oral consumption became
widespread throughout the USA and Europe as it was included in tonics, patent
medicines, soft drinks and even wine.
34
Its pharmacological properties were
investigated by Sigmund Freud who noted its local anaesthetic and psychic eVects.
He initially recommended it as a cure for morphine addiction, but later became
aware of its dependence liability.
The process of extracting cocaine is carried out in illegal factories often situated
in the jungle close to where the coca shrubs are grown. Cocaine hydrochloride of a
high degree of purity is obtained. It is a white powder, easy to transport and
smuggle and is often diluted (cut) with adulterants such as sugar, amphetamine
or local anaesthetics (Appendix 1).
Routes of administration
Cocaine may be administered by almost any route. Intravenous use has long been
popular with serious drug users because the drug reaches the brain rapidly and
subjective eVects, including an intense rush or high, are reported within 1 or 2
minutes. They also abate rapidly, over the next 30 minutes or so.
118 Drugs of abuse and dependence
A common way of taking cocaine is by sniYng (snorting) it. A line of cocaine
hydrochloride (2030 mg) is laid out and inhaled through a straw and the drug is
absorbed through the vascular mucous membranes lining the nose. Because
cocaine causes vasoconstriction (narrowing of the blood vessels), drug absorption
is slowed and there is no rush. However, a period of pleasurable stimulation and
euphoria occurs, lasting for 2040 minutes. SniYng is simpler than injecting and
carries no risk of infective complications, but repeated intranasal use of cocaine
damages the nasal mucous membrane causing chronic inXammation (rhinitis)
and sometimes a perforated nasal septum.
Smoking cocaine has recently become popular. This practice originated in
South America in the 1970s when coca paste, a crude derivative of coca leaves, was
mixed with tobacco or marijuana and smoked.
35
Cocaine hydrochloride is unsuit-
able for smoking because it decomposes at high temperatures. However, when the
cocaine alkaloid is freed from its hydrochloride base by a chemical reaction
involving ether, it has a melting point of 98Cand is volatile at temperatures above
90C. It therefore vaporizes very easily when heated, and the drug is rapidly and
eYciently absorbed from the lungs.
Another formof cocaine freebase is crack, which is prepared by a simple process
of cooking cocaine with baking powder and water. The baking powder precipi-
tates out any impurities or adulterants, leaving pure, crystalline cocaine which is
cracked into chips which are marketed in small phials. Because each phial con-
tains only a very small quantity of cocaine it is comparatively cheap, so that
cocaine, once available only to the wealthy, has become accessible to many more
people.
PuriWed cocaine base is usually smoked in a glass water pipe, or it may be
sprinkled on a tobacco or marijuana cigarette. It produces a sudden, intense high,
(the rush or Xash) comparable to that produced by intravenous injection,
because the cocaine is absorbed very rapidly by the large surface area of the lungs
and reaches the brain within seconds. The euphoria abates equally quickly, leaving
the user feeling restless and irritable and craving for another dose. The cocaine
user often appears unable to titrate or adjust the dosage and the frequency of
administration and the quantity inhaled escalates rapidly. Inhalations may be
repeated as often as every 5 minutes during binges that may last from hours to
days. Smoking continues until supplies are Wnished or the user falls asleep
exhausted.
Effects
Cocaine is a powerful central nervous system stimulant producing increased
energy, wakefulness, activity and conWdence and facilitating social interchange.
Most important of all it is a powerful euphoriant, giving the user a great feeling of
well-being.
119 Stimulant drugs
This euphoriant property is utilized when cocaine is included in elixirs (e.g.
Brompton Cocktail) used for the treatment of pain in terminally ill patients.
These elixirs also contain heroin or morphine, and cocaine counteracts what
might otherwise be an undesirable degree of sedation.
The physical eVects of cocaine include a raised pulse rate, blood pressure and
temperature, and dilated pupils. In addition to its local anaesthetic properties,
cocaine also causes local vasoconstriction (narrowing of blood vessels) so that it
was once widely used in ear, nose and throat surgery because it reduced haemor-
rhage. Now, however, it has been replaced by less toxic synthetic local anaes-
thetics.
36
It is still used in eye drops for ophthalmic surgery.
Very large doses, taken by those who are not used to it, cause hypertension,
cardiac arrhythmias and convulsions. Death may occur due to cardiac or respir-
atory arrest. There have also been reports of intracerebral haemorrhage in young
adults following stimulant abuse and this often seemed to be related to an
underlying vascular malformation which does not withstand the hypertensive
surge following stimulant administration. Mortality and morbidity from this
cause is greater than in those who have not used illegal drugs and may be due to
the intensity and duration of vasospasm being worsened by the use of cocaine,
together with an underlying poor state of health.
37
Tolerance
It used to be believed that tolerance to cocaine did not occur and that large doses
were taken only in a search for greater euphoria, rather than because small doses
were no longer eVective. These observations were based on cocaine users who
snorted cocaine hydrochloride intermittently, in what was described as usual
recreational doses, which were probably insuYcient to induce tolerance.
Now that pure cocaine freebase is available, a very diVerent picture is emerging.
Some users may take huge doses 30 g in 24 hours has been reported that would
undoubtedly be toxic to a cocaine-naive individual, but which the regular user can
take without serious complication because of the development of tolerance to the
hyperthermic, convulsant and cardiovascular eVects of cocaine. It is less clear
whether tolerance develops to the euphorigenic properties of cocaine; if it does,
this would contribute to dose escalation. However, as the dose and frequency of
consumption increase, dysphoric eVects of cocaine, such as irritability, suspicious-
ness and restlessness occur, suggesting that there is a ceiling to tolerance of
cocaines psychic eVects.
Tolerance does not seem to develop to the reinforcing eVect of cocaine.
Physical dependence
A variety of symptoms have been described following cocaine withdrawal by users
who habitually consume very large doses. The symptoms include lethargy,
120 Drugs of abuse and dependence
depression, apathy, social withdrawal, tremor, muscle pain and disturbances of
eating and sleeping (as well as EEG (electroencephalograph) changes). When
severe, they form a syndrome known as the crash, which begins 1530 minutes
after a binge and which may last for a fewhours or up to a fewdays, accompanied
by dysphoria and high levels of craving.
38,39
There may also be excessive sleepiness,
paranoid ideas, agitation and suicidal thoughts. When this acute phase subsides,
there is a longer period, lasting for several weeks, when anxiety, craving and
dysphoria may recur and when the risk of relapse is high. Only later, in the
extinction phase, which lasts for 312 months, do symptoms subside completely
but, even then, exposure to particular cues may stimulate craving again.
40,41
Despite long-standing opinion to the contrary, it is diYcult to believe that the
crash could be anything but the cocaine abstinence syndrome, although it does not
cause the major physiological disruption associated with the more familiar absti-
nence syndromes of opioids, alcohol or sedative hypnotics.
Psychological dependence
Cocaine causes severe psychological dependence with craving and drug-seeking
behaviour so intense that the normal pattern of life is disrupted and everything
becomes subservient to the need to obtain cocaine. In the early stages, a weekend
user, accustomed to having a good time if he or she takes cocaine, Wnds that
nothing is quite as enjoyable without it, and eventually that he or she is incapable
of enjoying anything if cocaine is not taken. Consumption extends gradually
through the week and it is then often taken speciWcally to relieve stress, because of
the learned experience of feeling better after cocaine. Severe psychological de-
pendence may develop quite rapidly, often without the user being aware that his or
her drug use is problematic.
In animals, cocaine is a powerful primary reinforcer: laboratory animals ex-
posed to cocaine will repeat an action more and more frequently in order to obtain
more cocaine and, given free access to it, will take the drug to the exclusion of food
so that they lose weight and die.
41,42
Until recently there was little evidence that
cocaine has such compelling eVects in humans and it was thought to be a safe
recreational drug, often glamorized as the drug of the rich and famous, for whom
sniYng was the most usual route of administration. The advent of pure cocaine
freebase has dramatically changed this view. Not only has it become apparent that
cocaine can cause tolerance and physical dependence, but new patterns of con-
sumption of cocaine have developed, with freebasers smoking cocaine almost
continuously until either they or the supply of drug are exhausted a behaviour
pattern remarkably similar to that observed in laboratory animals. It has been
suggested that this pattern of drug use is caused by the high concentrations of
cocaine in the brain that are achieved by smoking cocaine freebase, and that last
121 Stimulant drugs
for only a few minutes before a rapid decline in concentration occurs. It is
possible, for example, that it is the sharp contrast between the rush and with-
drawal that generates the drive to use more drug within a short period.
Mechanismof action
The mechanism of action of cocaine is complex and is not fully understood.
However, it is now known that there are speciWc cocaine receptors in the central
nervous system that bind cocaine molecules and which aVect the brains
dopaminergic system by inhibiting the reuptake of dopamine from synapses. The
consequent increase in dopamine at the synapse is thought to be associated with
euphoria but, with long-term use, the excessive dopamine is metabolized, leading
to reduced dopamine concentration. This in turn leads to changes in the post-
synaptic receptors which are thought to be associated with craving.
Cocaine also acts on the noradrenergic and 5-hydroxytryptamine systems
within the brain, inhibiting the reuptake of these neurotransmitters. The conse-
quent increase in noradrenalin at synapses leads to the stimulatory eVects of
tachycardia, hypertension, sweating, tremor, mydriasis, etc.
38
Cocaine toxicity/psychosis
As the dose and frequency of use of cocaine increase, adverse reactions may occur.
These start with feelings of anxiety, restlessness and apprehension and progress to
suspiciousness, hypervigilance and paranoid behaviour. Stimulation of the nerv-
ous system occurs causing muscle twitching, nausea and vomiting, increases
in pulse and blood pressure, irregular respiration and sometimes convulsions.
In cases of severe toxicity, this is followed by depression of the nervous system
with circulatory and respiratory failure, loss of reXexes, unconsciousness and
death.
Cocaine psychosis has also been described with persecutory delusions and
repetitive (stereotyped) behaviour such as compulsively taking a watch or radio
apart and reassembling it or repeatedly tidying or rearranging a set of objects.
There may be auditory hallucinations and sometimes tactile hallucinations, classi-
cally described as a sensation of insects crawling under the skin (cocaine bugs)
and causing incessant picking at the skin, or scratching. These symptoms are
indistinguishable from the toxic symptoms caused by other stimulants such as
amphetamine, but last for a shorter time and may come to medical attention less
often.
4345
Because of the adverse eVects of cocaine when it is taken in high dosage, the
cocaine user Wnds him or herself in a dilemma. The unpleasant symptoms of drug
withdrawal and above all the intense craving for cocaine, making discontinuing
it almost impossible, but continued consumption of large doses leads to the
122 Drugs of abuse and dependence
unpleasant symptoms outlined above. Other drugs, such as alcohol and other
central nervous system depressants, may then be taken to counteract the un-
wanted eVects of cocaine and the drug abuser may become (unwittingly) physical-
ly dependent on them too. Overdose and intoxication with these drugs is also
common. It should also be noted that cocaine is often adulterated with synthetic
local anaesthetics such as procaine or lignocaine which, when consumed in large
doses, may cause convulsions.
Khat
Khat is a tree, Catha edulis, that grows at high altitude in East Africa, Yemen and
Democratic Yemen, where the leaves and young shoots have been used for their
stimulant eVect for hundreds of years. Modern methods of transport have made it
easy to export khat and to bring regular supplies of fresh leaves to markets in
towns and cities in Democratic Yemen, Ethiopia, Somalia, Yemen, Kenya and
Tanzania. Recent reports suggest that it is now exported widely in vacuum packs
for the beneWt of expatriate communities.
Nowadays khat is usually chewed, although in the past an infusion of the leaves
was prepared (Arabian or Ethiopian tea). The khat leaves are plucked from the
twig and are chewed; the juicy extract is swallowed and the leafy residue is kept as a
wad in one side of the mouth. In Yemen it is usually taken in a group setting at
special parties, drinks are served and tobacco is smoked either as cigarettes or in a
water pipe.
One alkaloid, cathine, was identiWed in khat a century ago. More recently, other
substances, including cathinone, have also been isolated. Although these constitu-
ent chemicals are controlled substances under international conventions, khat
itself is not controlled.
Effects
Khat aVects the digestive system, commonly causing anorexia and constipation.
Stomatitis (inXammation of the mouth), gastritis and dyspepsia have also been
reported.
46
In the cardiovascular system there is a temporary increase in pulse rate
and blood pressure, palpitations and Xushing of the face.
Khat is chewed because of its ability to produce cerebral stimulation. Because of
this it was traditionally consumed by tribal people when travelling, and nowadays
is taken by long-distance lorry drivers and by students preparing for examinations.
It produces a general sense of well-being and when taken in a group setting (as it
traditionally is) it elevates the mood of the group and promotes social inter-
action.
47
After a few hours, however, the mood of the group changes and some
participants become restless and irritable. It may cause sleeplessness which in turn
may lead to the abuse of alcohol or sedative hypnotic drugs. It has been reported
123 Hallucinogens
that khat may (rarely) cause a toxic psychosis or schizophrenic reaction in
predisposed individuals.
48
Dependence
There is no evidence of a clear-cut abstinence syndrome and thus no evidence of
physical dependence on khat. Psychological dependence does develop, and in
cities in Somalia and Yemen it is estimated that a consumer may spend 25% of his
daily earnings on khat, thus causing Wnancial hardship to his family.
49,50
Although the problems associated with the use of khat may seem minor in
comparison with those of other drugs of abuse, khat should not be ignored. Until
recently it had been used only locally where it was grown, and even now because
the leaves must be fresh when they are chewed, their area of distribution has
remained fairly localized. However, the active ingredient of khat, cathinone, has
now been isolated and, in experiments on laboratory animals, has been shown to
have primary reinforcing properties similar to those of cocaine.
51
If pure
cathinone were to become available on the street, it is possible that it would cause
severe psychological dependence and that it would be extensively abused. Already,
in countries where khat is not cultivated and has to be imported, its use raises
major socioeconomic issues and these, together with the medical complications of
its use, have been considered by some countries serious enough to warrant the
introduction of preventive measures (prohibition).
52
There are clear similarities between the present state of khat abuse and the way
in which cocaine abuse began. Already, khat is being cultivated for export. It
would indeed be tragic if the rest of the world waited in ignorance while a new
drug of dependence and abuse was systematically extracted, marketed and ex-
ported. The lessons learned from the history of cocaine should not be forgotten
too quickly.
Hallucinogens
Lysergic acid diethylamide (LSD)
LSD was Wrst synthesized in 1938 by Hofmann. It is derived from ergot, a fungus
that grows on rye grains and is a white, crystalline powder soluble in water and
eVective in such minute quantities that doses are measured in micrograms. It is
taken orally and its eVects can be felt with a dose of only 25 g although a more
usual dose would be 100 g.
53
It was originally sold on sugar cubes and on small,
Xat strips known as microdots, and is now available on squares of paper, rather
like stamps (Appendix 1).
The physical eVects of LSD consumption are apparent within a few minutes.
They include nausea, headache, dilated pupils, raised pulse rate, a small and
124 Drugs of abuse and dependence
variable alteration of blood pressure and perhaps an increase in body temperature.
The mechanism of action of LSD and related drugs is not clear. They act at
multiple sites in the central nervous system, with an agonistic action at presynaptic
receptors for 5-hydroxytryptamine (5-HT, serotonin) in the mid-brain, where the
Wring rate of neurones was sharply reduced following small systemic doses of
LSD.
54
Effects
The psychological eVects of LSD are very variable, depending on the expectations
and mood of the subject and the setting in which the drug is taken. Their onset
follows the somatic symptoms and they persist for several hours.
Characteristically there are changes in perception, especially in the more experi-
enced user. These aVect all senses, particularly vision, and may take many diVerent
forms: stationary objects appear to move and change shape; some things become
minute while previously ignored details loom large and assume importance;
colours become more intense. There is often a cross-over of perceptions (synaes-
thesia) so that sounds are seen or felt and colours are heard. Distortions of
body image are common: a limb may appear to shrink, or become enormous and
may seem completely separate from the rest of the body. The perception of time is
often distorted too, with clock time passing very slowly.
Although LSD and similar drugs are often described or classiWed as hallucino-
gens, these perceptual changes are often illusions (the altered perception of an
existing object) rather than true hallucinations (perception in the absence of
stimulus). The latter do occur sometimes, although auditory hallucinations arise
less frequently than in naturally occurring psychoses.
In addition to these striking perceptual changes, LSD also aVects thinking
processes and mood, and induces feelings that are rarely, if ever, experienced at
other times. The user may feel that he or she has achieved union with and a unique
understanding of mankind, God and the universe, but often lacks the language to
describe what has obviously been a profound experience. Sometimes the experien-
ces are wonderful and exalting, although they may be overwhelmingly frightening.
It is thus not surprising that the mood of the LSD user is labile, moving through
anxiety, apprehension, gaiety and depression in a way that may be incomprehensi-
ble to an observer. The subject may be withdrawn and introspective, preoccupied
with these experiences and, because LSD also aVects thought processes, may show
impaired concentration, distractibility and illogical thinking and be totally out of
touch with others and unable to explain what is happening.
It should now be apparent why LSD and other similar drugs are often described
as psychedelic or mind-expanding; it enables the user to experience a mental state
which he or she would otherwise be unlikely to achieve. There is no evidence,
125 Hallucinogens
however, that these apparently profound and, at the time, very meaningful
experiences aVect the personality or subsequent behaviour in a beneWcial way.
However, at one stage, LSD was used as an aid to psychotherapy, because it was
believed that it would enable events of psychodynamic importance to be relived.
SpeciWc receptors have not been identiWed for LSD but it seems likely that its
eVects are due to agonist activity on serotonin receptors. Serotonin, also known as
5-hydroxytryptamine (5HT), is a neurotransmitter, widely distributed through-
out the central nervous system and elsewhere in the body, which acts by regulating
ion channels in the cell membrane so that the concentration of potassium and
calcium in the cell is changed. There are diVerent types of 5HT receptors and LSD
has greatest aYnity for the 5-HT
2
receptor, where it acts as a partial agonist.
29
Tolerance and dependence
Tolerance to the eVects of LSD develops so rapidly that a second dose of the drug
taken within 24 hours has less eVect than the Wrst, and after three or four daily
doses, subsequent administration has little or no psychological eVect. Because of
this there is no incentive to take it regularly on a daily basis, psychological and
physical dependence do not develop and withdrawal phenomena are not ob-
served. Tolerance is lost equally rapidly and after 3 or 4 days of abstinence, full
sensitivity to the eVects of LSD is regained. Chronic users usually take LSDonce or
more a week, often in large doses. Tolerance to the cardiovascular eVects of LSD is
less pronounced.
Adverse effects
The most common adverse eVect of LSD is a bad trip an unpleasant, often
terrifying drug experience that leads to a temporary episode of overwhelming
anxiety and panic which may last for up to 24 hours. A bad trip cannot be
predicted or prevented and may happen to any user, even after a number of
previously pleasurable experiences. Its occurrence is presumably related in some
way to the mental state of the user and the setting in which drug consumption
occurred.
Serious, even fatal, accidents may occur during a period of LSD intoxication.
They may be due to the individuals belief in supernatural powers or in an ability
to perform the impossible such as Xying, walking on water, etc. Such events
receive much publicity but occur only rarely.
Spontaneous, involuntary recurrences of the drug-induced experience (Xash-
backs) are fairly common after LSD use and may be troublesome if they occur
frequently. They may also be precipitated by the use of another drug such as
cannabis.
It is not clear whether LSD can cause prolonged psychotic illness. When such an
126 Drugs of abuse and dependence
illness does occur after LSDuse, it is generally believed that it would have occurred
anyway and that its onset was merely precipitated by LSD. Nevertheless, given the
psychotomimetic properties of LSD, it is possible that it plays a more causal role in
vulnerable individuals.
55
Other hallucinogenic drugs
There are several drugs whose psychological eVects are similar to those of LSD and
which are also described as hallucinogenic, psychedelic or psychotomimetic.
Many are derived from plants which have been used for a long time in religious
rituals. Indeed it has been suggested that there are hundreds of thousands of
species of hallucinogenic plants in the world. Mescalin, for example, is obtained
from the peyote cactus which is traditionally chewed by Indians in Mexico, while
psilocin and psilocybin come from a particular (magic) mushroom in Mexico;
lysergic acid monoethylamide, which has mild hallucinogenic properties, is found
in the seeds of the morning glory plant; and there are hallucinogens in plants such
as nutmeg, mace and deadly nightshade. Cross-tolerance occurs between LSD,
mescaline and psilocybin.
In addition to naturally occurring drugs, a whole range of synthetic compounds
are available, including DMT (dimethyltryptamine), DMA (dimethoxy-
amphetamine) and DOM (dimethoxymethylamphetamine) which are similar in
their eVects to LSD, but also have some amphetamine-like properties. DOMis also
known as STP (standing for serenity, tranquillity and peace) and has a longer
duration of action than LSD.
Other drugs, such as MDA (methylenedioxyamphetamine) and MMDA
(methoxymethylenedioxyamphetamine) are probably LSD-like but have other
properties as well.
The particular problems posed by these new drug analogues are discussed in the
section on designer drugs.
Phencyclidine (PCP)
PCP also produces changes in mood and perception, but is quite distinct from the
psychedelic drugs described above. It is related to pethidine and induces a marked
sensory blockade. First introduced as a veterinary anaesthetic, its property of
causing patients to feel detached from bodily sensations and therefore unaware of
pain, suggested a revolutionary approach to anaesthesia for humans.
56
However,
this was soon abandoned because it so often made patients agitated and deluded.
It became, however, a drug of abuse, particularly in the USA where it is known as
angel dust. It is relatively easy to synthesize illicitly and is often passed oV as LSD.
It is usually smoked or snorted.
EVects of PCP vary according to the dose consumed but as there is great
individual variation of response, even small doses may cause profound eVects in
127 Cannabis
some people. The desired eVect is a euphoric sensation of Xoating, usually
accompanied by mild numbness of the extremities, but the cerebellar eVects of
PCP simultaneously cause staggering gait, slurred speech and nystagmus.
56
Slight
increases in dose may precipitate severe muscular rigidity, hypertension and a
noncommunicative state. The risk of convulsions and coma becomes greater if
more than 20 mg is consumed.
The psychological eVects of PCP are very unpredictable; there may be percep-
tual disturbances, hallucinations, elevation of mood, restlessness, anxiety or para-
noia. Sometimes the patient is frankly psychotic and there may be aggressive and
bizarre behaviour.
57
The acute eVects of PCP last for 46 hours, followed by a long
period of coming down.
Tolerance and dependence
Tolerance to the eVects of PCP develops in animals and humans. Most of those
who abuse it probably take it about once a week, although some people have runs
of using it for 2 or 3 days at a time. Craving for the drug occurs in some people and
the depression and disorientation that occurs after a run of drug use may represent
a mild abstinence syndrome. The fact that monkeys will self-administer PCP (but
not LSD) also suggests that it may have some dependence potential. However, it is
rarely abused in Europe (as yet).
Cannabis
Cannabis is obtained from the Indian hemp plant Cannabis sativa, which is grown
in many countries as a source of rope Wbre. When the plant is fully grown, its
Xowers and upper leaves are covered with a sticky resin which contains psycho-
active substances collectively known as cannabinoids. There are probably more
than 50 of these, of which the most important is -9-tetrahydrocannabinol
(THC). The potency of a particular preparation of cannabis is related to its THC
content, which in turn depends on the part of the plant that is gathered and the
environmental conditions, particularly the climate, where it is grown. Certain
varieties of Cannabis sativa are cultivated speciWcally for their resin in some
tropical countries in the Caribbean, South America, South-East Asia, Indian
Subcontinent, etc. Hydroponic cultivation of cannabis is now undertaken in some
countries, where the climate is unsuitable for traditional methods and, combined
with careful plant selection, leads to very high concentrations of THC (2030%).
Preparations
Various preparations of cannabis are available, often known by diVerent names in
diVerent countries.
128 Drugs of abuse and dependence
1 Bhang: the dried leaves and Xowering tops of uncultivated plants, which are
infused and drunk;
2 Marijuana: the dried leaves and Xowering tops of uncultivated plants, which are
smoked;
3 Ganja: small upper leaves and Xowering tops of cultivated female plants, which
are smoked. It is about three times as potent as marijuana;
The THC content of these three herbals preparations is between 1% and 10%.
4 Hashish/charas/cannabis resin: the pure resin fromthe Xowering tops and leaves
of female plants. It is in the form of a sticky brown cake which is usually
smoked. The THC content varies between 8% and 15%.
5 Liquid cannabis/hashish oil: this is obtained by subjecting cannabis resin to
extraction with a nonaqueous solvent. After Wltration and evaporation, a brown
syrupy liquid is obtained into which tobacco is dipped before smoking. It may
contain up to 60% THC.
An average marijuana cigarette in the UK usually contains 300500mg of
herbal material with a THC content of perhaps 12%. Even if smoked by an
experienced user, only 50% of the available THC is absorbed and so the estimated
dose of THC from one cigarette is in the region of 2.55.0 mg. However, the dose
may also vary because heat converts some inactive compounds into THC and can
inactivate psychoactive cannabinoids.
58
With the introduction of varieties of
cannabis with very high concentrations of THC, the THC content of individual
cigarettes can now be much higher than previously.
Absorption and fate of THC
THC is absorbed very quickly across the large surface area of the lungs and plasma
concentrations peak very quickly (1030 minutes). THC binds tightly to blood
proteins but, because it is so fat soluble, it is readily absorbed by organs such as the
brain which have a high fat content and is released only slowly back into the
bloodstream. It is metabolized (broken down), mostly in the liver, to 11-hydroxy
THC, which is 20% more potent than THC itself, and to other products with
unknown or relatively little psychoactive eVect.
59
The eVects of a single marijuana
cigarette are apparent within minutes and last for 23 hours. When cannabis is
consumed orally, the onset of action is slower than if it is smoked and a larger dose
is required to obtain the same eVects, which then last longer.
60
Because of their fat solubility, THC and its metabolites remain for long periods
of time in the fatty tissues of the body. Thus, 5 days after a single injection of THC,
20% remains stored and 20% of its metabolites remain in the blood; complete
elimination of a single dose may take 30 days. Given this slow rate of clearance, it is
likely that repeated administration may lead to accumulation of THC and its
metabolites in the body.
61
An awareness of these pharmacokinetics is relevant to
any discussion about the long-term eVects of cannabis.
129 Cannabis
Effects
The physical eVects commonly associated with cannabis use include dryness of the
mouth, hunger, reddening of the eyes and reduced pressure in the intraocular
Xuid of the eyes. There may be increased blood pressure (together with postural
hypotension) and a dose-related increase in heart rate. Chronic, high-dosage
eVects of cannabis are reported to include reduced testosterone level and sperm
count, as well as reduced fertility in women and reduced fetal birth weight.
Gynaecomastia may occur.
The psychological eVects of smoking a marijuana cigarette are well known. The
desired and sought after eVects are of euphoria, self-conWdence, relaxation and a
general sense of well-being. There is often an altered perception of time, which
may appear to be passing more slowly than usual, and the perception of hearing,
taste, touch and smell may seem to the subject to be enhanced, although there is
no objective evidence of this on formal testing. It may be diYcult for the subject to
concentrate and memory may be impaired. Sometimes these experiences are not
pleasurable and the subject becomes anxious, agitated and suspicious, occasionally
experiencing a severe panic reaction. Although there is no conclusive evidence, it
is likely that the ability to drive a car safely is adversely aVected by cannabis
consumption.
The mental set of the subject and the setting in which cannabis is taken may
both inXuence the drug-induced experience, although laboratory experiments
have provided conclusive evidence that the psychological eVects of cannabis are
due to its THC content. In small doses, equivalent to smoking one marijuana
cigarette, THCcauses changes in mood (usually euphoria) and altered perception.
With bigger doses (200250 g/kg; approximately 15 mg THC for an average,
70 kg man), there is marked distortion in visual and auditory perception, and
hallucinations occur in most subjects together with sensations of depersonaliz-
ation and derealization. Thinking becomes confused and disorganized and para-
noid feelings are common. With even higher doses, a frank toxic psychosis
develops.
It appears, therefore, that THC, the main constituent of cannabis, is a psycho-
tomimetic drug; in other words it can produce a state similar to that of a psychotic
illness and this eVect depends on the dose that is administered. In the laboratory
the reaction of the same individual to the same dose is reproducible on diVerent
occasions and some individuals are unusually sensitive to THC, experiencing
psychosis even at low doses.
Two cannabinoid receptors have recently been identiWed in the brain, CB
1
and
CB
2
. CB
1
is the central receptor that binds 11-hydroxy THC, which inhibits the
release of GABAinto the synaptic cleft. There appear to be high levels of binding in
the hippocampus, a part of the brain particularly associated with memory. This
may account for some of the observed psychological eVects of cannabis.
62
130 Drugs of abuse and dependence
Tolerance
The development of tolerance to the eVects of cannabis has long been a controver-
sial issue. In Western countries it is often claimed that cannabis does not cause
tolerance, on the grounds that experienced users continue to obtain a high from
their Wrst cigarette of the day. Indeed, the phenomenon of reverse tolerance has
been described, when experienced users may report more subjective experiences
than novices. These observations and opinions are contradicted by the experience
of countries where heavy, regular consumption of cannabis is common. In these
countries, very large doses may be consumed (hundreds of milligrams of THC)
that would undoubtedly be toxic to a drug-naive individual, suggesting that
tolerance to the eVects of THC has indeed developed.
Laboratory experiments also conWrm the existence of tolerance to cannabis-
induced changes in mood, tachycardia (increased heart rate), decreased intra-
ocular pressure and impairment of performance in psychomotor tests. Tolerance
develops rapidly, within a few days of regular drug use, and decays rapidly when
drug use ceases. It is generally much less obvious than tolerance to heroin or
cocaine, and the irregular small doses of cannabis that are usually consumed in
Western countries may not be suYcient to cause a noticeable degree of tolerance.
Furthermore, there appears to be an upper limit to tolerance to cannabis, which
may vary from individual to individual, and once this is reached further increases
in dose may precipitate the onset of psychotic symptoms.
Dependence
Similar controversy surrounds the question of dependence on cannabis. Again, it
is not surprising that dependence is reported most frequently in those countries
where cannabis is consumed regularly and in large quantities. In this situation,
cannabis withdrawal is followed by some discomfort and an abstinence syndrome,
the hallmark of physical dependence, has been described. It is characterized by
irritability, restlessness, decreased appetite, weight loss and insomnia. These clini-
cal observations are supported by the observation under laboratory conditions of
a withdrawal syndrome in volunteers who had taken high doses of THCfor several
weeks. This experiment conWrmed that the syndrome is relatively mild, starting a
few hours after the cessation of drug administration and lasting for 45 days.
The issue of whether tolerance develops to cannabis and its dependence liability
is particularly important because of continuing discussions in many countries
about its decriminalization. The recent observation that monkeys self-administer
THC is therefore of great interest.
63
In this experiment the monkeys gave them-
selves about 30 injections of THC during an hour-long session, self-administering
a dose that was roughly equivalent to that obtained by a person smoking a
marijuana joint. It was also noted that self-administration was blocked by a
131 Cannabis
cannabinoid receptor blocker. This suggests that THC has primary reinforcing
properties that are qualitatively similar to those of heroin and cocaine, both of
which are drugs that animals will self-administer. However, there is no doubt that
craving and drug-seeking behaviour, the hallmark of severe dependence, rarely
occur among those who misuse cannabis.
Cannabis psychosis
World-wide, millions of people smoke marijuana and consume cannabis in
diVerent forms, and there have been many reports, from all over the world, of
cannabis psychosis, a psychotic illness arising after the consumption of a large
quantity of cannabis. It is characterized by the sudden onset of confusion,
generally associated with delusions, hallucinations and emotional lability. Tem-
porary amnesia, disorientation, depersonalization and paranoid symptoms are
also common. This toxic mental state may persist for a few hours or a few
days.
58,64,65
This syndrome is well recognized and frequently reported in countries,
such as India, West Indies and in South-East Asia, where heavy consumption of
cannabis is common,
66
but its existence is often questioned in the UK and other
Western countries. Here, the THC content of the cannabis that is available is often
low and even experienced users usually smoke only a few cigarettes, perhaps two
or three times a week, or even daily a far cry from Jamaican heavy users whose
consumption of THC is estimated to be 420 mg daily. As toxic psychosis is a
dose-related eVect of cannabis, it is only to be expected that there would be a
smaller incidence of the syndrome in the UK, although it seems likely that there is
a general lack of awareness of its existence and consequent underdiagnosis.
Furthermore, it seems likely that many users are familiar with the eVects of
cannabis and are able to titrate their intake to avoid unpleasant eVects. Mild
intoxication is undoubtedly dealt with, without recourse to medical advice.
58
It has also been suggested, although there is little Wrm evidence, that cannabis
can cause a functional psychosis a paranoid schizophrenia-like illness in a setting
of clear consciousness. There are many alternative explanations for any apparent
relationship between cannabis and psychosis: that the patient was psychotic
anyway and cannabis use was incidental or merely aggravated the existing condi-
tion; that the patient was potentially psychotic and this was precipitated by
cannabis, which cannot cause psychosis in a normal individual; that the illness
preceded and indirectly caused cannabis use. Although these and other explana-
tions may be true, they do not preclude the existence of a cannabis-induced
functional psychosis, and those who are experienced in the sequelae of prolonged
and heavy cannabis abuse have observed subtle diVerences between true paranoid
schizophrenia and the psychotic illness that sometimes develops in cannabis
abusers.
67,68
For example, the latter are more likely to have hypomanic symptoms,
132 Drugs of abuse and dependence
but less likely to have schizophrenic-type thought disorder. Their illness re-
sponds very swiftly to antipsychotic medication, but tends to relapse if cannabis
use is resumed.
There is, however, no evidence that cannabis causes a chronic psychosis that
persists after drug use is discontinued, although some patients may eVectively
maintain themselves in a psychotic condition by continuing to consume large
quantities of cannabis.
69
Flashbacks
Flashbacks are spontaneous, involuntary recurrences of drug-induced experiences
after the eVects of the drug have worn oV. They have been described following
cannabis use, but the generally accepted wisdom is that they only occur if the
patient has previously used other psychotomimetic drugs such as LSD
65
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9
9
8
Guidelines on completion of the form
The S.A.M. Collaborative Project
The aim of the project is to give service providers who participate, good quality information on
the utilization of services by clients, paying particular attention to the eVectiveness of treatment
interventions, by measuring outcomes in terms of the clients quality of life. Resulting data will
also be of great beneWt to purchasers and commissioners of substance misuse services.
As well as providing quality data at a local level, the data can be forwarded and included in the
Department of Health regional and national statistics.
The project is supervised by the Addiction Resource Agency for commissioners at the Centre
for Addiction Studies, St Georges Hospital Medical School.
WHO the form is about
Any client with whom you have contact who has a recent substance problem of any kind. A
broad view of substance use is adopted, including all psychoactive drugs with the exclusion only
of tobacco. Prescribed drugs (such as benzodiazepines) should be included as well as over-the-
counter preparations (such as codeine linctus). Alcohol use should also be recorded in the
appropriate slot provided in the Substance ProWle table.
WHEN to complete the form
Please complete a form when the client Wrst presents to your agency, and whenever a new
episode of substance use starts. A new episode starts when a person with substance-related
problems either goes to a particular agency for the Wrst time, or returns to a particular agency
after an interval of 6 months or more.
WHO completes the form
This form is intended for completion by a staV member who has interviewed a client. It is not
intended as a self-completion form for drug users. Please ensure that you complete the initial
section which asks for basic information about you (the interviewer) and the agency for which
you work.
WHERE does it go
Please send all completed forms to the S.A.M. Project at the end of each month.
Confidentiality and anonymity
All data entered onto the Database is password protected. The password is known only to the
Project Manager and the data-entry clerk. Summarized information only is contained in reports
to third parties and this never contains client information (such as initials, date of birth or full
postcode).
DiVerent levels of personal identiWcation may be chosen according to client/agency prefer-
ences. Acode (allocated by your agency) may be submitted in place of initials and an age in place
of date of birth.
408 Appendix 2
This means that it is not possible to check for double-counting at agency level. It is therefore
essential that each new episode is only reported once by your agency to the Database.
Data Protection Act
The database is registered with the Data Protection Registrar. It is considered good practice to
inform clients about the purposes of the database, that it is conWdential and that their rights are
protected under the Data Protection Act.
Forms (top copy) should be returned to:
409 Substance Abuse Database
MMMM
Appendix 3. The European Substance Use
Database
The European Substance Use Database (EuroSUD) is a brief initial assessment instrument
collecting basic demographic data about drug users who present to services, as well as informa-
tion about their current drug using behaviour and the types of treatment intervention oVered to
them. The information contained on the EuroSUD may be used for either clinical or research
purposes. The Database itself is a valuable epidemiological tool at local, national and interna-
tional levels. EuroSUD computer programs, written in shareware software, enable data entry
and report generation at local level at minimal cost. The EuroSUD is currently in use in
treatment centres in 10 European countries.
411
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Appendix 4. Substance Abuse Assessment
Questionnaire
Part I Preliminary Assessment
Name of interviewer: ...........................................................................................................................................
INDEX NO. [ ] [ ] [ ] [ ] [ ] 15
STUDY NO. [ ] [ ] 67
CARD NO. [0] [1] 89
Section I (a) INITIAL INFORMATION (General assessment)
1. Date of interview: [ ] [ ] [ ] [ ] [ ] [ ] 1015
2. Place of interview: [ ] 16
1 Treatment centre
2 Hospital
3 Home
4 Other (specify): ............................................................................................................................
3. Date of referral: [ ][ ][ ][ ][ ][ ] 1722
4. Clients name: ........................................................................................................[ ][ ] 2324
5. Clients address: .................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
[ ][ ][ ][ ][ ][ ] 2530
Tel No: ...............................................................................................................
Post Code: .........................................................................................................
6. Clients sex [ ] 31
1 Male 2 Female
7. Clients date of birth: [ ][ ][ ][ ][ ][ ] 3237
For example, 1 September, 1963=[0][1] [0][9] [6][3]
99 99 99 =Not known
8. Clients age: [ ][ ] 3839
414
9. Ethnic group: [ ][ ] 4041
01 British 09 Pakistani
02 Irish 10 Bangladeshi
03 Any other White background 11 Any other Asian background
04 White and Black Caribbean 12 Caribbean
05 White and Black African 13 African
06 White and Asian 14 Any other Black background
07 Any other mixed background 15 Chinese
08 Indian 16 Any other*
99 Not known
*Specify.............................................................
10. Marital status: [ ] 42
1 Single
2 Married/Cohabiting
3 Separated
4 Divorced
5 Widowed
9 Not known
11. Number of children: [ ][ ] 4344
12. Ages of children to nearest whole year: [ ][ ] 4546
[ ][ ] 4748
[ ][ ] 4950
[ ][ ] 5152
[ ][ ] 5354
Should the client have more than 5 children please place the youngest childs age in the Wrst
two boxes and the eldest childs age in the last two boxes.
13. Does client have a . . .
1 Yes 2 No 8 Not applicable 9 Not known
Family Doctor [ ] 55
Social Worker [ ] 56
Probation OYcer [ ] 57
Other Professional Care Worker, [ ] 58
Please Specify .............................................................................................................
Name and address of key person:
.....................................................................................................................................
.....................................................................................................................................
Tel: ..............................................................................................................................
14. Source of Referral: [ ][ ] 5960
01 Self
02 Family/Friend/Cohabitee
03 Family Doctor/Community Health Centre
04 Accident & Emergency/Hospital
415 Substance Abuse Assessment Questionnaire
05 Other Drug Clinic
06 Psychiatric Service
07 Police
08 Probation/Courts/Lawyer
09 Social Services
10 Voluntary Agency/Hostel
11 Other (Specify) ..................................................................................................
99 Not known
15. Current Living Arrangements: [ ][ ] 61
01 Alone
02 With Spouse or partner
03 With Spouse/Partner and children
04 Self and children
05 Friends/Hostel
06 Parents
07 Other (Specify) ..................................................................................................
99 Not known
16. Type of accommodation at address: [ ][ ] 6263
01 Parental home
02 Owned by Client and/or his/her spouse/partner
03 Rented house/Xat
04 Squat
05 Hospital
06 Therapeutic Community
07 Probation Hostel
08 Prison
09 No Wxed abode
10 Other (Specify) ..................................................................................................
99 Not known
17. Education Number of years of schooling completed [ ][ ] 6465
88 Still attending
99 Not known
18. Schooling: [ ] 66
1 No formal education
2 Special Educational Needs
3 No QualiWcations
4 High School QualiWcations
5 Professional QualiWcations
6 Degree/Diploma
19. Occupational Status: [ ][ ] 6768
01 Unemployed
02 Employed
03 Self-employed
04 Child care/Housewife
05 Student
06 Armed Forces
416 Appendix 4
07 National Service
08 Retired
09 Voluntary Work
10 Other (Specify) ..................................................................................................
99 Not known
20. Current/usual job .............................................................................................. *[ ][ ] 6970
*Local Coding System to be used
21. Longest period of unemployment:
years months
[ ][ ] [ ][ ] 7174
88 Not applicable (still at school/college)
99 Not known
22. Longest period in same job:
years months
[ ][ ] [ ][ ] 7578
88 Not applicable (still at school/never employed)
99 Not known
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][2] 89
23. How many jobs has Client had since leaving school?
number [ ][ ] 1011
88 Not applicable (still at school/college)
99 Not known
00 Never employed
24. Reason for attendance
1 Yes 2 No 8 Not applicable 9 Not known
Financial [ ] 12
Job [ ] 13
Family/Relationships [ ] 14
Medical [ ] 15
Psychological [ ] 16
Housing [ ] 17
Pregnancy [ ] 18
Accident and Emergency [ ] 19
Needle Exchange [ ] 20
Other (Specify) .......................................................................................................... [ ] 21
25. Are there any other Agencies involved with the Client?
[ ] 22
1 Yes 2 No 8 Not applicable 9 Not known
If Yes, specify .............................................................................................................
..............................................................................................................
..............................................................................................................
26. Has Client received treatment for their drug use before? [ ] 23
1 Yes 2 No 8 Not applicable 9 Not known
417 Substance Abuse Assessment Questionnaire
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2. How were you introduced to drug taking? [ ] 52
1 Partner
2 Sibling
3 Friend or acquaintance
4 Parent or relative
5 Drug dealer
6 Doctor (include therapeutic addicts)
7 Other (please specify) .............................................................................................
9 Not known
3. How long do you consider that you have had a drug problem?
years months 5356
[ ][ ] [ ][ ]
99 Not known
For example, four and a half years =[0][4] [0][6]
4. Have you experienced any of the following symptoms over the last six months?
1 Yes 2 No 9 Not known
Opiate Withdrawals [ ] 57
Sedative Withdrawals [ ] 58
Convulsions [ ] 59
Hallucinations [ ] 60
Paranoid State [ ] 61
Depersonalization [ ] 62
Derealization [ ] 63
Flashbacks [ ] 64
5. How soon after you wake up in the morning do you use drugs? [ ] 65
1 Immediately
2 After breakfast/a few hours
3 After several hours
4 Not known
6. How much money do you estimate you spend in an average week on drugs?
Please state currency: .................................................................................................................
[ ][ ][ ][ ][ ][ ] 6673
7. Have you been absent from work for more than 2 days in last month because
of drug use? [ ] 74
1 Yes 2 No 8 Not applicable 9 Not known
420 Appendix 4
8. In last 12 months how many weeks have you been totally drug free?
Insert number of weeks [ ][ ] 7576
99 Not known
For example, Seven weeks =[0][7], No weeks =[0][0]
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][5] 89
9. Have you ever received any of the following treatments for your drug use?
1 Yes 2 No 9 Not known
Through voluntary/self-help group [ ] 10
Through your Family Doctor [ ] 11
Private Practice [ ] 12
Substance Misuse Team (outpatient/community) [ ] 13
As inpatient [ ] 14
As resident in rehabilitation [ ] 15
Other (please specify): .............................................................................................. [ ] 16
Please state when and where treatment took place, if known:
Date Place
[ ][ ]/[ ][ ]/[ ][ ] [ ] 1722
[ ][ ]/[ ][ ]/[ ][ ] [ ] 2328
[ ][ ]/[ ][ ]/[ ][ ] [ ] 2934
[ ][ ]/[ ][ ]/[ ][ ] [ ] 3540
10. How many cigarettes (tobacco) do you smoke in a day?
[ ][ ] 4142
98 Occasional smoker
88 Does not smoke
99 Not known
11. How soon after you wake up in the morning do you smoke?
[ ] 43
1 Immediately 5 Within six hours
2 Within the Wrst hour 8 Not applicable
3 Within three hours 9 Not known
4 Evening only (i.e. 6 p.m. onwards)
421 Substance Abuse Assessment Questionnaire
12. ASSESSMENT RATING (Drug Use)
(1) Do you see your present drug use as: [ ] 44
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(2) Do you think you need help because of your drug use [ ] 45
0 No need 1 Limited need 2 Moderate need 3 Serious need
(3) Does interviewer think Clients drug use is: [ ] 46
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(4) Does interviewer assess Clients need for help with drug problem as: [ ] 47
0 No need 1 Limited need 2 Moderate need 3 Serious need
NOTES:
422 Appendix 4
Section I (c) ALCOHOL USE
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][6] 89
1. Do you consider you have ever had problems with alcohol?
1 Yes 2 No 9 Not known [ ] 10
2. Do you consider you have current problems with alcohol (within the last 12 months)?
1 Yes 2 No 9 Not known [ ] 11
3. Have you ever been convicted of alcohol related oVences?
1 Yes 2 No 9 Not known [ ] 12
For example, drink/driving, drunk and disorderly, breach of the peace
4. Are you suVering Wnancial hardship due to the amount you spend on alcohol?
1 Yes 2 No 9 Not known [ ] 13
5. Do you think your relationships are suVering due to the amount of alcohol you drink?
1 Yes 2 No 9 Not known [ ] 14
6. Have you been absent from work for more than two days in the last month because of drink?
1 Yes 2 No 8 Not applicable 9 Not known [ ] 15
7. Number of standard drinks consumed in an average week:
grams [ ][ ][ ] 1618
or units [ ][ ][ ] 1921
Calculation Formula:
1 Unit of alcohol =8 g of absolute alcohol
No. of alcohol units =% Alcohol By Volume (ABV) amount of beverage (in ml)
8. Have you experienced any of the following symptoms over the last six months related to alcohol
consumption?
1 Yes 2 No 9 Not known
423 Substance Abuse Assessment Questionnaire
Morning drinking [ ] 22
Morning nausea/vomiting [ ] 23
Shakes [ ] 24
Sweating [ ] 25
Anxiety/panic attacks [ ] 26
Depression [ ] 27
Loss of memory [ ] 28
Blackouts [ ] 29
Delirium Tremens [ ] 30
Convulsions [ ] 31
Hallucinations [ ] 32
9. On average how many days in a week do you consume alcohol? [ ] 33
9 Not known
10. What is your usual style of drinking? [ ] 34
1 Weekend/other short episodes
2 Bouts of more than two days
3 Steady, daily
4 Other, specify .......................................................................................................................
8 Not applicable
9 Not known
11. If you drink in bouts what is their average duration?
days weeks months
[ ][ ] [ ][ ] [ ][ ] 3540
12. What is the average length of time between bouts?
days weeks months
[ ][ ] [ ][ ] [ ][ ] 4146
13. In the last year how many weeks have you been alcohol free?
[ ][ ] 4748
88 Not applicable
99 Not known
14. How long do you think you have had a problem with alcohol?
years months
[ ][ ] [ ][ ] 4952
88 Not applicable
99 Not known
15. Have you ever had treatment for your problem with alcohol? [ ] 53
1 Yes
2 No
8 Not applicable (i.e. no alcohol problem)
424 Appendix 4
9 Not known
If the answer to question 15 is no treatment leave all boxes blank and go to next question.
16. Treatment received:
1 Yes 2 No 9 Not known
Family Doctor treatment [ ] 54
As hospital out-patient [ ] 55
As hospital in-patient [ ] 56
Community Alcohol Team [ ] 57
Non-statutory/Voluntary agency [ ] 58
Other (specify): [ ] 59
Please state when and where treatment took place, if known:
Date Place
[ ][ ]/[ ][ ]/[ ][ ] [ ]6065
[ ][ ]/[ ][ ]/[ ][ ] [ ]6671
17. ASSESSMENT RATING (Alcohol)
(1) How do you rate your alcohol use? [ ] 72
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(2) Do you think you need help with an alcohol problem? [ ] 73
0 No need 1 Limited need 2 Moderate need 3 Serious need
(3) How does interviewer rate Clients alcohol problem? [ ] 74
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(4) Does interviewer think Client needs help with alcohol problem? [ ] 75
0 No need 1 Limited need 2 Moderate need 3 Serious need
NOTES:
425 Substance Abuse Assessment Questionnaire
Section I (d) SUMMARY OF REQUESTS AND REQUIREMENTS
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][7] 89
1. What treatment is Client asking for?
1 Yes 2 No 9 Not known
Out-patient Programmes
Programme Client requests
Interviewers initial
recommendation
Out-patient Detox Programme
Opiate
Sedative
Stimulants
Alcohol
[ ]
[ ]
[ ]
[ ]
[ ] 1011
[ ] 1213
[ ] 1415
[ ] 1617
Out-patient Maintenance Programme
Opiate
Sedative
Stimulants
[ ]
[ ]
[ ]
[ ] 1819
[ ] 2021
[ ] 2223
In-patient Assessment Prior to any of the above [ ] 24
In-patient Programmes
Programme Client requests
Interviewers initial
recommendation
In-patient Detox Programmes
Opiate
Sedative
Stimulant
Alcohol
[ ]
[ ]
[ ]
[ ]
[ ] 2526
[ ] 2728
[ ] 2930
[ ] 3132
In-patient treatment other
(specify)
.................................................................... [ ] [ ] 3334
Residential Recovery/Rehab [ ] [ ] 3536
426 Appendix 4
Day Care
Programme
Client
requests
Interviewers initial
recommendation
Day Care [ ] [ ] 3738
Other Options
Treatment for physical health
(specify)
.................................................................. [ ] [ ] 3940
Treatment for psychiatric health
problem (specify)
.................................................................. [ ] [ ] 4142
Naltrexone
DisulWram
NET
Acupuncture
Needle Exchange
HIV Counselling/Testing
Psychological Interventions
Other, please specify:
..................................................................
..................................................................
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ]
[ ] 4344
[ ] 4546
[ ] 4748
[ ] 4950
[ ] 5152
[ ] 5354
[ ] 5556
[ ] 5758
[ ] 5960
Social Work assistance [ ] [ ] 6162
Court report [ ] [ ] 6364
2. At the time of this interview was the client: [ ] 65
1 Sober 2 Intoxicated 3 Withdrawing 9 Not known
3. SUMMARY RATING (General Preliminary Assessment: Sections 1a, 1b, 1c and 1d)
(1) Does Client perceive their present situation as: [ ] 66
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(2) Does Client perceive their present need for help as: [ ] 67
0 No need 1 Limited need 2 Moderate need 3 Serious need
(3) Does interviewer perceive Clients present situation as: [ ] 68
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(4) Does interviewer perceive Clients need for help as: [ ] 69
0 No need 1 Limited need 2 Moderate need 3 Serious need
427 Substance Abuse Assessment Questionnaire
NOTES:
428 Appendix 4
Part II Comprehensive Assessment
Section II MEDICAL AND MENTAL HEALTH ASSESSMENT
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][8] 89
Section II (a) PHYSICAL HEALTH
1. Have you any complaints about your present state of physical health and/or do you suVer any
disability?
1 Yes 2 No 9 Not known [ ] 10
If Yes, specify: ....................................................................................................................................
...................................................................................................................................
2. What is your appetite like?
1 Good 2 Poor 9 Not known [ ] 11
3. How do you sleep?
1 Well 2 Poorly 9 Not known [ ] 12
4. Are you presently receiving any treatment for a physical illness and/or disability?
1 Yes 2 No 9 Not known
From Family Doctor: [ ] 13
From Hospital, Out-patient: [ ] 14
From Hospital, In-patient: [ ] 15
Other (specify) ........................................................................................................ [ ] 16
What is the illness/disability? *[ ][ ][ ][ ][ ] 1721
*Local Coding System to be used
......................................................................................................................................................
What is the treatment? *[ ][ ] 2223
*Local Coding System to be used
......................................................................................................................................................
If receiving prescribed drugs (apart from methadone) please give names:
*Local Coding System to be used
...........................................................................................................................*[ ][ ][ ] 2426
......................................................................................................................................................
5. Have you ever been hospitalized in the last two years for a physical illness?
1 Yes 2 No 8 Not applicable 9 Not known [ ] 27
If Yes, specify:
429 Substance Abuse Assessment Questionnaire
Nature of illness
Age at
which it
occurred
Length of
admission
(months)
6. Have you ever injected? [ ] 28
1 Yes 2 No 9 Not known
If No, go to question 11
7. Which method(s) of injecting do you use?
1 Yes 2 No 9 Not known
Intravenous (I.V.) [ ] 29
Intramuscular (I.M.) [ ] 30
Subcutaneous (Skin-popping) [ ] 31
8. Which sites do you use?
1 Yes 2 No 9 Not known
Arm [ ] 32
Groin [ ] 33
Feet [ ] 34
Neck [ ] 35
Other (specify): ................................................................................................... [ ] 36
9. Have you ever shared? [ ] 37
1 Yes 2 No 9 Not known
10. How long ago was most recent sharing?
years months days
[ ][ ] [ ][ ] [ ][ ] 3843
11. Has an HIV test ever been oVered to you? [ ] 44
1 Yes 2 No 9 Not known
12. Did you take up the oVer of testing? [ ] 45
1 Yes 2 No 9 Not known
13. Have you ever completed a Hep B vaccination course? [ ] 46
1 Yes 2 No 9 Not known
14. Have you ever had any of the following?
1 Yes 2 No 9 Not known
HIV [ ] 47
Hepatitis B [ ] 48
430 Appendix 4
Hepatitis C [ ] 49
Septicaemia [ ] 50
Abscesses [ ] 51
Endocarditis [ ] 52
Over-dose (deliberate) [ ] 53
Over-dose (accidental) [ ] 54
Other (specify): ................................................................................................... [ ] 55
Female Clients Only
Amenorrheoa [ ] 56
Miscarriage/spontaneous abortion [ ] 57
Termination of pregnancy [ ] 58
15. PHYSICAL EXAMINATION
(a) General Physical Examination
1 Yes 2 No 9 Not known
Poor dental care [ ] 59
Injection marks on skin [ ] 60
Tattoos [ ] 61
Abscesses [ ] 62
Anaemia [ ] 63
Malnutrition [ ] 64
Lymphadenopathy [ ] 65
Jaundice [ ] 66
(b) Systems Examination
1 Normal 2 Abnormal (specify) 9 Not known
Specify Code
Cardiovascular System [ ] 67
Respiratory [ ] 68
Alimentary [ ] 69
Urogenital [ ] 70
Endocrine [ ] 71
Nervous System [ ] 72
Locomotor [ ] 73
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [0][9] 89
16. Blood Pressure:
Systolic [ ][ ][ ] 1012
Diastolic [ ][ ][ ] 1315
Pulse [ ][ ][ ] 1618
431 Substance Abuse Assessment Questionnaire
17. LABORATORY INVESTIGATIONS:
(a) Hepatitis Screen 1 Positive 2 Negative 8 Not done 9 Not known
Type Date of result Code
B antibody [ ][ ]/[ ][ ]/[ ][ ] [ ] 1925
B antigen [ ][ ]/[ ][ ]/[ ][ ] [ ] 2632
C antibody [ ][ ]/[ ][ ]/[ ][ ] [ ] 3339
C antigen [ ][ ]/[ ][ ]/[ ][ ] [ ] 4046
(b) HIV Screen 1 Positive 2 Negative 8 Not done 9 Not known
Date of result Code
[ ][ ]/[ ][ ]/[ ][ ] [ ] 4753
(c) Electrolytes and Urea 1 Normal 2 Abnormal 8 Not done 9 Not known
Date of result If abnormal, specify: Code
[ ][ ]/[ ][ ]/[ ][ ] [ ] 5460
(d) Liver Function Test 1 Normal 2 Abnormal 8 Not done 9 Not known
Date of result If abnormal, specify: Code
[ ][ ]/[ ][ ]/[ ][ ] [ ] 6167
(e) Full Blood Count 1 Normal 2 Abnormal 8 Not done 9 Not known
Date of result If abnormal, specify: Code
[ ][ ]/[ ][ ]/[ ][ ] [ ] 6874
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][0] 89
432 Appendix 4
(f ) X-rays 1 Normal 2 Abnormal 8 Not done 9 Not known
Date of result If abnormal, specify: Code
[ ][ ]/[ ][ ]/[ ][ ] [ ] 1016
18. URINE RESULTS
1 Positive 2 Negative 8 Not done 9 Not known
Date:
//
Date:
//
Date:
//
Date:
// 1740
Drug result result result result
Morphine [ ] [ ] [ ] [ ] 4144
Methadone [ ] [ ] [ ] [ ] 4549
Other Opiates [ ] [ ] [ ] [ ] 5054
Amphetamines [ ] [ ] [ ] [ ] 5559
Cocaine [ ] [ ] [ ] [ ] 6064
Barbiturates [ ] [ ] [ ] [ ] 6569
Benzodiazepines [ ] [ ] [ ] [ ] 7074
Cannabis [ ] [ ] [ ] [ ] 7579
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][1] 89
Alcohol [ ] [ ] [ ] [ ] 1014
Other (specify) [ ] [ ] [ ] [ ] 1519
19. ASSESSMENT RATING (Physical Health)
(1) How would you rate your physical health at present? [ ] 20
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(2) Do you think you need help with physical health
problems? [ ] 21
0 No need 1 Limited need 2 Moderate need 3 Serious need
(3) How does interviewer rate Clients physical health? [ ] 22
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(4) Does interviewer think Client needs help with physical health problems?[ ] 23
0 No need 1 Limited need 2 Moderate need 3 Serious need
433 Substance Abuse Assessment Questionnaire
NOTES:
434 Appendix 4
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][2] 89
Section II (b) MENTAL HEALTH
18. Are you presently receiving treatment for a mental health problem? (Except drug/alcohol use):
1 Yes 2 No 9 Not known
From Family Doctor [ ] 10
Hospital (Out-patient/Day patient) [ ] 11
Hospital (In-patient) [ ] 12
Community Mental Health Team [ ] 13
Other (specify): .......................................................................................................... [ ] 14
What is the illness/problem? *[ ][ ][ ][ ][ ] 1519
*Local Coding System to be used
.........................................................................................................................................
.........................................................................................................................................
What is the treatment? *[ ][ ] 2021
*Local Coding System to be used
.........................................................................................................................................
.........................................................................................................................................
If receiving prescribed drugs please give names:
*Local Coding System to be used
*[ ][ ][ ] 2224
.........................................................................................................................................
.........................................................................................................................................
19. Have you ever been a hospital in-patient because of mental illness? [ ] 25
1 Yes 2 No 9 Not known
If Yes, please specify
Nature of illness Age Date
[ ][ ] [ ][ ]/[ ][ ]/[ ][ ] . . . 2633
[ ][ ] [ ][ ]/[ ][ ]/[ ][ ] . . . 3441
[ ][ ] [ ][ ]/[ ][ ]/[ ][ ] . . . 4250
20. What is your sexual orientation? [ ] 51
1 Exclusively heterosexual
2 Mainly heterosexual
435 Substance Abuse Assessment Questionnaire
3 Mainly homosexual
4 Bisexual
5 Exclusively homosexual
9 Not known
21. Do you consider you have any problem with your sexual functioning? [ ] 50
1 Yes (secondary to drug/alcohol use)
2 Yes (other reason)
3 No
9 Not known
If Yes, please specify
.........................................................................................................................................
22. Mental State
1 Normal 2 Abnormal (specify) 9 Not known
Specify abnormality Code
Appearance [ ] 51
Behaviour [ ] 52
Mood [ ] 53
Talk [ ] 54
Thought [ ] 55
Perception [ ] 56
Insight [ ] 57
Cognitive function [ ] 58
Orientation [ ] 59
Concentration [ ] 60
Memory [ ] 61
Intelligence [ ] 62
Other [ ] 63
23. At the time of the mental state being carried out, was client [ ] 64
1 Sober 2 Intoxicated 3 Withdrawing 9 Not known
436 Appendix 4
24. ASSESSMENT RATING (Mental Health)
(1) How would you rate your mental health at present? [ ] 65
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(2) Do you think you need help with mental health problems? [ ] 66
0 No need 1 Limited need 2 Moderate need 3 Serious need
(3) How does interviewer rate Clients mental health? [ ] 67
0 No problem 1 Limited problem 2 Moderate problem
3 Serious problem
(4) Does interviewer think Client needs help with mental health? [ ] 68
0 No need 1 Limited need 2 Moderate need 3 Serious need
NOTES:
437 Substance Abuse Assessment Questionnaire
Section III FORENSIC ASSESSMENT
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][3] 89
1. Have you ever been involved in any criminal activity? [ ] 10
1 Yes 2 No 9 Not known
If answer to this question is No: STOP HERE, leave all intervening boxes blank, and go to
question 11.
2. At what age did you Wrst become involved in criminal activity? [ ][ ] 11
99 Not known
3. Do you at present have any court cases pending? [ ][ ] 12
1 Yes 2 No 9 Not known
If answer is Yes, please specify for what oVence(s):
*Local Coding System to be used.
.............................................................................................................................
............................................................................................................................. *[ ][ ] 1314
4. Are you at present on: . . .
1 Yes 2 No 9 Not known
Condition of treatment [ ] 15
Probation [ ] 16
Suspended sentence [ ] 17
Deferred sentence [ ] 18
Parole [ ] 19
Other (specify) ........................................................................................................... [ ] 20
5.
If answer is yes, please specify for what oVence(s)
*Local Coding System to be used
.....................................................................................................................................
............................................................................................................................. *[ ][ ] 2122
6. Which of the following types of oVences have you ever
committed, and number of convictions?
1 Yes 2 No 9 Not known
438 Appendix 4
OVences
Committed before
drug use began
Committed after
drug use began
Number of
convictions
Drug related [ ] [ ] [ ] [ ] 2326
Driving [ ] [ ] [ ] [ ] 2730
Public disorder [ ] [ ] [ ] [ ] 3134
Violence against
property [ ] [ ] [ ] [ ] 3538
Crimes of acquisition [ ] [ ] [ ] [ ] 3942
Sex oVences [ ] [ ] [ ] [ ] 4346
Violence against the
person [ ] [ ] [ ] [ ] 4750
7. Have you had any periods of imprisonment? [ ][ ] 5152
If yes, code number of times, i.e. three times =[0][3]
99 =Not known
88 =Never been in prison
8. If you have been in prison, what was the longest sentence served?
days months years
[ ][ ] [ ][ ] [ ][ ] 5358
99 Not known
9. Whilst in prison did you continue to use drugs?
1 Yes, frequently 3 Yes, occasionally
2 No 9 Not known [ ] 59
10. Of the crimes committed since the onset of drug use, what percentage do you estimate were
committed whilst intoxicated?
percentage %
[ ][ ] 6061
99 Not known
11. ASSESSMENT RATING (Forensic/Legal)
(1) How severe would you rate your legal problems as being at the moment? [ ] 62
0 No problems 1 Limited problems 2 Moderate problems
3 Serious problems
(2) Do you think you need help with your legal problems at present? [ ] 63
0 No need 1 Limited need 2 Moderate need 3 Serious need [ ]
(3) Does the interviewer think the Clients present legal problems are: [ ] 64
0 No problems 1 Limited problems 2 Moderate problems
3 Serious problems
(4) How much help does the interviewer think the Client needs with legal problems? [ ] 65
0 No need 1 Limited need 2 Moderate need 3 Serious need [ ]
439 Substance Abuse Assessment Questionnaire
NOTES:
440 Appendix 4
Section IV PSYCHOSOCIAL AND FAMILY ASSESSMENT
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][4] 89
1. Do you have a Social Worker already involved with yourself or your family [ ] 10
1 Yes 2 No 9 Not known
Name and address .....................................................................................................
....................................................................................................
Tel: .............................................................................................
2. Number of siblings
Male [ ][ ] 1112
Female [ ][ ] 1314
88 None
99 Not known
3. What position are you in birth order? [ ][ ] 1516
01 First
02 Second (etc.)
99 Not applicable (only child)
4. Are you a twin? [ ] 17
1 Yes, identical twin
2 Yes, non-identical twin
3 No
9 Not known
5. Fathers occupation/last job [ ] 1819
Please specify
*Local Coding System to be used
.....................................................................................................................................
6. Fathers age [ ][ ] 2021
or age at death? [ ][ ] 2122
10 Not applicable (i.e. father unknown)
99 Not known
7. Mothers occupation/last job: [ ][ ]* 2324
Please specify
*Local Coding System to be used
.....................................................................................................................................
8. Mothers age [ ][ ] 2526
or age at death? [ ][ ] 2728
10 Not applicable(i.e. mother unknown)
99 Not known
441 Substance Abuse Assessment Questionnaire
9. Are members of the immediate family aware of drug use?
1 Yes 2 No 8 Not applicable 9 Not known
Parents [ ] 29
Partner [ ] 30
Children [ ] 31
10. Are members of the immediate family aware of alcohol problem?
1 Yes 2 No 8 Not applicable 9 Not known
Parents [ ] 32
Partner [ ] 33
Children [ ] 34
11. If you are married or have a regular partner, what is partners occupation? [ ][ ] 3536
Please specify
*Local Coding System to be used
.....................................................................................................................................
12. Are you worried about your children in any of the following areas?
1 Yes 2 No 8 No children 9 Not known
Code
Problems at home [ ] 37
Problems at school [ ] 38
Problems with police [ ] 39
Using drugs/alcohol [ ] 40
Physical health/handicap [ ] 41
Mental health/handicap [ ] 42
13. Are any of your children, under the age of 16 years, living away from you at present?
1 Yes 2 No 8 No children 9 Not known
With other parent/family member [ ] 43
Under the care of Statutory Supervision [ ] 44
Other reasons (please specify):
..................................................................................................................................... [ ] 45
Include here, e.g. attending special school, children have left home, children in hostel, etc.
14. Are any of your children on a Statutory Protection Register (i.e. At Risk Register)
1 Yes 2 No 8 No children 9 Not known
If Yes, please specify *Local Coding System to be used
............................................................................................................................. [ ][ ]* 4647
15. Have any of your children been on a Statutory Protection Register (i.e. At Risk Register)
in the past?
442 Appendix 4
1 Yes 2 No 8 No Children 9 Not known
If Yes, please specify* Local Coding System to be used
............................................................................................................................. [ ][ ]* 4849
16. Do you usually use drugs: [ ] 50
1 Alone
2 With others
8 Not applicable (never uses drugs)
9 Not known
17. What proportion of friends/associates take drugs?
percentage % [ ][ ] 5152
88 Not applicable (never uses drugs)
99 Not known
18. What percentage of your time is spent in drug seeking/drug using?
percentage % [ ][ ] 5354
88 Not applicable (never uses drugs)
99 Not known
19. Over the last 12 months have any of the following caused you particular concern?
1 Yes, serious concern 2 Yes, moderate concern
3 Yes, slight concern 4 No concern
9 Not known
Event Code
Problems at work [ ] 55
Financial hardship [ ] 56
Housing diYculties [ ] 57
Partners drug/alcohol abuse [ ] 58
Ill health in the family [ ] 59
Relationship/marital discord [ ] 60
Violence in the family [ ] 61
Separation from children [ ] 62
Separation from partner/spouse [ ] 63
Bereavement [ ] 64
Other, specify [ ] 65
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][5] 89
443 Substance Abuse Assessment Questionnaire
20. Have any members of your family suVered from a psychiatric illness/dependency on drugs
and/or alcohol?
1 Yes 2 No 8 Not applicable 9 Not known
Member of family Psychiatric illness Dependency on drugs Dependency on alcohol
Father [ ] [ ] [ ] 1012
Mother [ ] [ ] [ ] 1315
Sibling(s) [ ] [ ] [ ] 1618
Children [ ] [ ] [ ] 1921
Partner [ ] [ ] [ ] 2224
Other, specify
.................................... [ ] [ ] [ ] 2527
If yes, please give ...................................... ...................................... ...........................................
details ...................................... ...................................... ...........................................
21. Do any members of your family have a criminal record?
1 Yes 2 No 8 Not applicable 9 Not known
Criminal details
Father [ ] 28
Mother [ ] 29
Sibling(s) [ ] 30
Partner [ ] 31
Children [ ] 32
Other (specify)
.............................. [ ] 33
.............................. [ ] 34
444 Appendix 4
22. During childhood or adolescence, was your family life disrupted by any of the following events?
1 Yes 2 No 3 Not known
Event Childhood
(012 years)
Adolescence
(1320 years)
Client went into care/fostered/adopted [ ] [ ] 3536
Frequent relocation [ ] [ ] 3738
Financial hardship [ ] [ ] 3940
Violence against Client [ ] [ ] 4142
Sexual assault [ ] [ ] 4344
Incest [ ] [ ] 4546
Marital discord between parents [ ] [ ] 4748
Violence between parents [ ] [ ] 4950
Separation/Divorce of parents [ ] [ ] 5152
Imprisonment of parent [ ] [ ] 5354
Hospitalization of parent for over 3/12 [ ] [ ] 5556
Death of sibling [ ] [ ] 5758
Death of father [ ] [ ] 5960
Death of mother [ ] [ ] 6162
Family joined by step-parent/step-siblings [ ] [ ] 6364
23. ASSESSMENT RATING (Psychosocial/Family)
(1) How concerned are you about social/family problems? [ ] 65
0 No concern 1 Limited concern 2 Moderate concern
3 Serious concern
(2) Do you think you need help with social/family problems? [ ] 66
0 No need 1 Limited need 2 Moderate need
3 Serious need
(3) How concerned is interviewer about Clients social/family problems? [ ] 67
0 No concern 1 Limited concern 2 Moderate concern
3 Serious concern
(4) Does interviewer think Client needs help with social/family problems? [ ] 68
0 No need 1 Limited need 2 Moderate need 3 Serious need
NOTES:
445 Substance Abuse Assessment Questionnaire
Section V ASSESSMENT PROFILE
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][6] 89
1. Did the Client complete assessment?
1 Yes 2 No 9 Not known [ ] 10
If Client failed to complete assessment, please state reason for dropping out
*Local Coding System to be used
...................................................................................................................... [ ][ ][ ][ ] 1114
......................................................................................................................
......................................................................................................................
......................................................................................................................
3. Principal Substance of Misuse
Please list in rank order, for example;
1=primary substance
8=not a problem now, or never used
9=not known
Opiates [ ] 15
Barbiturates [ ] 16
Benzodiazepines [ ] 17
Amphetamine [ ] 18
Cocaine [ ] 19
Other stimulants [ ] 20
Psychotropics (including LSD & Cannabis) [ ] 21
Alcohol [ ] 22
Solvents/Inhalants [ ] 23
4. Overall Assessment Rating Scores
Insert corresponding scores from assessment ratings for each section
446 Appendix 4
Clients
Perception
Care Workers
Perception
Problem Need Problem Need Box codes
Drug [ ] [ ] [ ] [ ]
2427
Alcohol [ ] [ ] [ ] [ ]
4043
General/Preliminary [ ] [ ] [ ] [ ]
2831
Physical [ ] [ ] [ ] [ ]
3235
Mental [ ] [ ] [ ] [ ]
3639
Legal/Forensic [ ] [ ] [ ] [ ]
4447
Psychosocial/Family [ ] [ ] [ ] [ ]
4851
The maximum problem/need score in each of the dimensions is 12.
Overall scoring is not deemed appropriate.
5. Diagnosis
Record as many coexisting mental disorders, general medical conditions and other
factors that are relevant to the care and treatment of the individual. The primary
diagnosis should be listed first. Please specify the classification systemused (DSM
III-R/DSM-IV/ICD-9/ICD-10)
ICD.../DSM...Name ICD.../DSM...CODE Box Code
[ ] [ ] [ ] . [ ] [ ] 4953
[ ] [ ] [ ] . [ ] [ ] 5458
[ ] [ ] [ ] . [ ] [ ] 5963
[ ] [ ] [ ] . [ ] [ ] 6468
FOR EXAMPLE
ICD.../DSM...Name ICD.../DSM...CODE Box Code
Alcohol Abuse (DSM-IV) [3] [0] [5] . [0] [0]
Dependent personality
Disorder (DSM-III-R) [3] [0] [1] . [6] [0]
Hypothyroidism (ICD-9-CM) [2] [4] [4] . [9] [ ]
447 Substance Abuse Assessment Questionnaire
6. Clients requirements (as perceived by Centre)
(a) Drug Problem Code
1 Requires in-patient treatment [ ] 69
2 Requires out-patient treatment [ ] 70
3 Requires in-patient treatment in DDU [ ] 71
4 Other (please specify):
[ ] 72
8 Not applicable [ ] 73
9 Not known [ ] 74
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][7] 89
(b) Physical Health Problem Code
1 Requires in-patient treatment in another hospital department [ ] 10
2 Requires in-patient treatment in drug treatment centre [ ] 11
3 Requires out-patient treatment in another hospital department [ ] 12
4 Requires out-patient treatment in drug treatment centre [ ] 13
5 Other (please specify) [ ] 14
8 Not applicable [ ] 15
9 Not known [ ] 16
(c) Mental health problem Code
1 Requires formal in-patient psychiatric treatment [ ] 54
2 Requires formal out-patient psychiatric treatment in another
hospital department [ ] 55
3 Requires out-patient treatment in this Centre [ ] 56
4 Other (please specify) [ ] 57
8 Not applicable [ ] 58
9 Not known [ ] 59
448 Appendix 4
Social problems Code
1 Requires referral to other agency [ ] 60
2 Requires help from this Centre [ ] 61
3 Other (please specify) [ ] 62
8 Not applicable [ ] 63
9 Not known [ ] 64
Section VI TREATMENT PROFILE
INDEX NO. [ ][ ][ ][ ][ ] 15
STUDY NO. [ ][ ] 67
CARD NO. [1][8] 89
1. What type of treatment was oVered to the Client? [ ] 10
1 Out-patient
2 Community Intervention
3 In-patient
4 Day Care
5 Residential Rehabilitation
2. Place of treatment [ ][ ] 1112
1 Specialized Out-Patient Drug Treatment Centre
2 General Out-Patient clinic
3 Clients home
4 Community Health Centre/Family Doctors surgery
5 Specialized In-Patient Drug Treatment Unit
6 General In-Patient Psychiatric Unit
7 General Medical/Surgical In-Patient Unit
8 Specialized Drug Day Programme
9 General Day Care Programme
10 Other (specify)
.............................................................................................................................
449 Substance Abuse Assessment Questionnaire
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4. Were any of the following General Treatment Measures oVered?
1 Yes 2 No 9 Not known
Code
Counselling [ ] 26
Individual psychotherapy [ ] 27
Behaviour therapy [ ] 28
Relaxation therapy [ ] 29
Family therapy [ ] 30
Joint marital therapy [ ] 31
Group therapy [ ] 32
Alcohol Support Group [ ] 33
Drug Use Support Group [ ] 34
Other, please state: [ ] 35
...........................................................................................
Treatment Plan
A precis of the treatment plan agreed by the client and keyworker should be documented. It
should include:
a) The nature of treatment
b) The order of interventions and their proposed duration
c) The ways in which treatment will be implemented
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
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..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
451 Substance Abuse Assessment Questionnaire
Section VII SUMMARY OF ASSESSMENT AND TREATMENT
This summary should provide an adequate basis for letters to family doctors, formal reports and
referrals and should include:
1. Reason and source of referral.
2. Date of assessment and discipline(s)of professionals involved.
3. Major substance(s) of use including the duration and pattern of use.
4. Previous treatment history and agencies involved.
5. Major problem areas and need for intervention.
6. Patients personality, motivation and other psychological factors.
7. Treatment goals (short-, medium- and long-term) and plan of action.
8. Formulation of the case.
..............................................................................................................................................................
..............................................................................................................................................................
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452 Appendix 4
Section VIII GUIDELINES ON SCORING THE SAAQ RATING SCALE
1. Problems Rating Score
Domain Score Category
1.1 Drug use 0 Abstinence or near abstinences from prescribed and illicit
drugs
1 Prescribed drugs or only occasional illicit drug use
2 Illicit drug use no injecting or only occasional injecting
3 Chaotic or regular injecting or sharing injecting equipment
1.2 Alcohol use 0 Abstinent or moderate alcohol use (M:=21 F:=14 u/
week)
1 Heavy drinking (M 2250 u/week; F1435 u/week)
2 Excessive drinking (M950; F935 u/week) and moderate
alcohol dependence
3 Severe alcohol dependence (e.g. severe withdrawal or morn-
ing relief drinking) or regular/prolonged binges
1.3 General/Preliminary 0 Abstinence or near abstinence from all substances no need
for signiWcant intervention
1 Moderate problems with substance misuse which has been
acknowledged by the client and/or noted by others need
for brief intervention
2 SigniWcant substance misuse problems need for specialist
intervention
3 Serious substance misuse problems with signiWcant risk of
harm to the client and/or others need for intensive inter-
ventions
1.4 Physical health 0 No physical health problems
1 Limited problems (e.g. weight loss, poor physical care, poor
diet)
2 Moderate problems (disabilities related to use, no acute
illness, absesses, ODs (non-DSH), asymptomatic HIV, hepa-
titis)
3 Serious problems (serious physical illness e.g. symptomatic
HIV, hepatitis, endocarditis, septicaemia, DVT)
1.5 Mental Health 0 No mental health problems
1 Limited problems (e.g. mild depression/anxiety)
2 Moderate problems (e.g. moderate depression/anxiety, sui-
cidal ideation, impulsive DSH attempt)
3 Serious problems (e.g. psychoses, severe depression, serious
DSH attempt)
453 Substance Abuse Assessment Questionnaire
1.6 Forensic/legal 0 No forensic or legal problems
1 Limited (e.g. shoplifting, occasional petty crime, no serious
oVences, possession)
2 Moderate (e.g. nonviolent crime, probation, Wnes, drunk
driving, or pending, possession with intent to supply)
3 Serious (e.g. violent oVences, sexual assault, rape, possible
imprisonment, traYcking)
1.7 Social/Family 0 No problems (no threat e.g. stable relationships, accommo-
dation, job)
1 Limited problems(threat e.g. threats to job, relationship,
housing)
2 Moderate problems (serious threat e.g. unstable relation-
ships, housing, work)
3 Serious problems (breakdown e.g. relationship breakdown,
violence, loss of job, eviction, homelessness, or threat of )
At intake score refers to the 6 month period before assessment
At reassessment refers to the previous 3 month period
2. Treatment need rating score
Scores on each domain are based upon the interviewers and clients rating of treatment need.
This refers to the patients need for continued or additional treatment at the time of assessment.
Refers to the need for treatment with a specialist drug agency or, in addition, a mental health
team (in the case of mental health) or a medical service (in the case of physical health).
0 No treatment need: No further treatment required.
1 Limited need: Further treatment desirable but not essential.
2 Moderate need: Needs further ongoing intensive treatment, in-patient
admission or residential rehabilitation.
3 Serious need: Needs ongoing intensive treatment, in-patient admission
or residential rehabilitation.
454 Appendix 4
Appendix 5. Np-SAD
Reporting Form
NOTIFICATION OF DRUG RELATED DEATH
Section 1. Demographic Information
Deceased Forename(s) Gender: Male Female
Family Name
Known Aliases:
Date of Birth / / Place of Birth
Usual Address
Postcode
Ethnicity (tick one):
British
Irish
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other*
*Specify
Occupational Status (tick one):
Employed (manual) Unemployed Retired Student
Employed (non-manual) Childcare/Houseperson Not known Self-employed
Invalidity/sick Other, specify
Living Arrangements (tick one):
Alone Self & children No Wxed abode
With partner With parent(s) Not known
Partner & children With friend(s) Other, specify
455
Section II. Circumstances of Death
Date of death / / Place of death:
Was the deceased on prescribed medication? Yes No/Not known
If yes, please list drugs: 1. 2. 3.
4. 5.
Was the deceased a drug addict or known drug abuser?
Yes No Not known
Please list drugs present at post mortem(including alcohol) which were implicated in the death:
1. 2. 3.
4. 5.
Section III. Causes of Death
1(a)
1(b)
2.
Coroners Verdict (if verdict is accident or misadventure, please also complete
Section IV)
Section IV. Accidental Deaths and Misadventure
Place where accident occurred (tick one only):
) Home ) Mine or quarry ) Residential institution
) Farm ) Street or highway ) Place of recreation/sport
) Industrial place ) Educational institution ) Other speciWed place
Details of accident:
Section V. Any other relevant information
Section VI. Coroners Details
Coroners Name: Date of Inquest: / /
Jurisdiction: OYce:
Signature: Date: / /
456 Appendix 5
Appendix 6. Narcotics Anonymous
The Twelve Steps
1. We admitted that we were powerless over our addiction, that our lives had become
unmanageable.
2. We came to believe that a Power greater than ourselves could restore us to sanity.
3. We made a decision to turn our will and our lives over to the care of God as we understood
God.
4. We made a searching and fearless moral inventory of ourselves.
5. We admitted to God, to ourselves, and to another human being the exact nature or our
wrongs.
6. We were entirely ready to have God remove all these defects of character.
7. We humbly asked God to remove our shortcomings.
8. We made a list of all persons we had harmed, and became willing to make amends to them
all.
9. We made direct amends to such people wherever possible, except when to do so would
injure them or others.
10. We continued to take personal inventory and when we were wrong promptly admitted it.
11. We sought through prayer and meditation to improve our conscious contact with God as
we understood God, praying only for knowledge of Gods will for us and the power to carry
that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to
addicts, and to practice these principles in all our aVairs.
The Twelve Traditions
We keep what we have only with vigilance, and just as freedom for the individual comes from
the Twelve Steps, so freedom for the group springs from our Traditions. As long as the ties that
bind us together are stronger than those that would tear us apart, all will be well.
1. Our common welfare should come Wrst: personal recovery depends on NA unity.
2. For our group purposes there is but one ultimate authority a loving God as He may
457
express Himself in our group conscience. Our leaders are but trusted servants, they do not
govern.
3. The only requirement for membership is a desire to stop using.
4. Each group should be autonomous except in matters aVecting other groups or NA as a
whole.
5. Each group has but one primary purpose to carry the message to the addict who still
suVers.
6. An NA group ought never to endorse, Wnance, or lend the NA name to any related facility
or outside enterprise, lest problems of money, property or prestige divert us from our
primary purpose.
7. Every NA group ought to be fully self-supporting, declining outside contributions.
8. Narcotics Anonymous should remain forever non-professional, but our service centres
may employ special workers.
9. NA, as such, ought never be organized, but we may create service boards or committees
directly responsible to those they serve.
10. Narcotics Anonymous has no opinion on outside issues; hence the NA name ought never
be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion: we need always
maintain personal anonymity at the level of press, radio and Wlms.
12. Anonymity is the spiritual foundation of all our Traditions, ever reminding us to place
principles before personalities.
The Twelve Steps of Alcoholics Anonymous
1. We admitted we were powerless over alcohol that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood
Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our
wrongs.
6. Were entirely ready to have God remove all the defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we
understood Him, praying only for knowledge of His will for us and the power to carry that
out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message
to alcoholics, and to practice these principles in all our aVairs.
Reprinted and adapted with permission of AA World Services, Inc.
458 Appendix 6
Appendix 7. Opiate withdrawal
Opiate Withdrawal Symptom Questionnaire
Patients name: Patient study no.
Please rate the absence or presence of the following symptoms over the past 24 hours using the
following scale at approximately the same time each day.
Scale 0=none/not at all 1=slightly/little/occasionally
2=moderately 3=very much/a great deal/continuously
Over the last 24 hours to Enter date
what extent have you: Enter time am/pm
1 Been yawning 10 Felt sick
2 Had muscle cramp 11 Had stomach cramps
3 Had pounding heart 12 Had diYculty sleeping
4 Had a runny nose 13 Felt aches in bones or muscles
5 Been sneezing 14 Felt twitching and shaking
6 Experienced pins and needles 15 Felt irritable/bad tempered
7 Had hot/cold Xushes 16 Been sweating
8 Had diarrhoea 17 Had runny eyes
9 Had gooseXesh 18 Felt craving
Total score (leave blank)
459
Appendix 8. Opiate Withdrawal Scoring Sheet
Patients name: Patient study no.
Before each dose of opiate please complete a set of observations, Wlling in the results below.
At the same time give patient a symptom questionnaire to Wll in.
Date and time of admission
Date
Time (24 hour)
Signs*
1 Yawning
2 Lacrimation
3 Rhinorrhoea
4 Perspiration
5 Tremor
6 Piloerection
7 Restlessness
8 Pupil size (mm)
9 Anorexia
10 Vomiting
11 Diarrhoea
12 Insomnia
13 Drug seeking
continued overleaf
460
Date
Time (24 hour)
Observations
Temperature
Respiration rate
Pulse
Blood pressure
Weight
Drugs
Dose of opiates
Other treatments
Adverse eVects
Comments
Other investigations
* Signs 113 should be determined as either: present =2; not sure =1; or absent =0.
Observations (+sign 8): record actual measurements.
461 Opiate Withdrawal Scoring Sheet
Appendix 9. Attendance Record
Name: Key worker: Doctor:
Date
Seen by
Reason for attendance*
Drug use in past 24 hours
Clinical state:
Intoxicated
sedated
elated
Sober
Withdrawing
opiate
sedative
Urine result lab no.
Amphetamine
Barbiturate
Benzodiazepine
Cannabis
Codeine
Cocaine
Methadone
Morphine
Other
*e.g. follow-up (f/u): daily attendance (d/a); assessment, blood test; special visit.
Score: +, ++, +++.
Note: This record is to be maintained at every attendance. To be completed by member of team
who formally sees the patient: key worker, doctor, clinic nurse, social worker, etc. 462
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Chapter 8
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ence, ed. AH Ghodse & D Maxwell, pp. 16231. London: Macmillan Press.
2. Riley D (1987). Management of the pregnant drug addict. Bulletin of the Royal College of
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3. Zuckerman B, Frank D & Brown E (1995). Overview of the eVects of abuse and drugs on
pregnancy and oVspring. In Medications Development for the Treatment of Pregnant Addicts
and their Infants, ed. CN Chiang & LP Finnegan, pp. 1638 (NIDA research monograph
149). Rockville, MD: NIDA.
4. Zuckerman B & Brown E (1993). Maternal substance abuse and infant development. In
Handbook of Infant Mental Health, ed. R Tsang, pp. 14358. New York: Guilford Press.
5. Finnegan LP & Kaltenbach K (1992). Neonatal abstinence syndrome. In Primary Pediatric
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7. The European Collaborative Study (1999). Maternal viral load and vertical transmission of
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482 References and further reading
8. HIV in pregnancy and early childhood (1999). Drug and Therapeutics Bulletin, 37(9),
657.
9. Department of Health (2001). Hepatitis C: Guidance for Those Working with Drug Users.
London: Department of Health. www.drugs.gov.uk
10. Kaltenbach K & Finnegan L (1997). Children of maternal substance misusers. Current
Opinion in Psychiatry, 10, 2204.
11. Brewster JM (1986). Prevalence of alcohol and other drug problems among physicians.
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12. Ghodse H (2000). Doctors and their health. Who heals the healers? In Doctors and Their
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other psychiatric disorders in a hospital population. British Journal of Addiction, 83,
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20. Ross HE, Swinson, R, Larkin EJ & Doumani S (1994). Diagnosing comorbidity in substance
abusers: computer assessment and clinical validation. Journal of Nervous and Mental
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21. Anthenelli RM (1994). The initial evaluation of the dual diagnosis patient. Psychiatric
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22. Farrell M, Howes S, Bebbington P, et al. (2001). Nicotine, alcohol and drug dependence and
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25. Crawford V (1996). Comorbidity of substance misuse and psychiatric disorders. Current
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26. Williams H, Salter M & Ghodse AH (1996). Management of substance misusers on the
general hospital ward. British Journal of Clinical Practice, 50, 948.
27. Ghodse AH, Stapleton J, Edwards G &Edeh J (1987). Monitoring changing patterns of drug
dependence in accident and emergency departments. Drug and Alcohol Dependence, 19,
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483 References and further reading
28. Richmond RL & Anderson P (1994). Research in general practice for smokers and excessive
drinkers in Australia and the UK. Addiction, 89, 3562.
29. Williams H & Ghodse AH (1996). The prevention of alcohol and drug misuse. In The
Prevention of Mental Illness in Primary Care. ed. A Kendrick, A Tylie & P Freeling,
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30. Robertson JR (1985). Drug users in contact with general practice. British Medical Journal,
290, 345.
31. Porter S &Ghodse AH (1996). Treatment of substance misuse problems in general practice.
In General Practice National Association of Fundholding Practices Yearbook, pp. 31821.
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32. Department of Health, The Scottish OYce Department of Health, Welsh OYce, Depart-
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Guidelines on Clinical Management. London: HMSO.
33. Royal College of Psychiatrists and Association of Police Surgeons (2000). Substance Misuse
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Chapter 10
1. WHO Expert Committee on Drug Dependence (1998). Thirtieth Report. Geneva: WHO.
2. US Department of Health and Human Services (1996). Treatment Works. Rockville, MD:
DHHS.
3. Rounsaville BJ, Tierney T, Crit-Cristoph K, Weissman MW & Kleber HD(1982). Predictors
of outcome in treatment of opiate addicts: evidence for the multidimensional nature of
addicts problems. Comprehensive Psychiatry, 23, 46278.
4. Stimson G & Oppenheimer E (1982). Heroin addiction. Treatment and Control in Britain,
pp. 22952. London: Tavistock.
5. Cottrell D, Childs-Clarke A & Ghodse AH (1985). British opiate addicts: an 11-year
follow-up. British Journal of Psychiatry, 146, 44850.
6. Rathod NH (1977). Follow-up study of injectors in a provincial town. Drug and Alcohol
Dependence, 2, 121.
7. Oppenheim GB, Wright JE, Buchanan J & Biggs L (1973). Outpatient treatment of narcotic
addiction: who beneWts? British Journal of Addiction, 68, 3744.
8. Thorley A (1981). Longitudinal studies of drug dependence. In Drug Problems in Britain: A
Review of Ten Years, ed. G Edwards & C Busch, pp. 11769. London: Academic Press.
9. Bewley TH, Ben-Arie O & James IP (1968). Morbidity and mortality from heroin depend-
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7256.
10. Ghodse AH, Sheehan M, Taylor C & Edwards G (1985). Deaths of drug addicts in the
United Kingdom, 19671981. British Medical Journal, 290, 4258.
11. Engstrom A, Adamsson C, Allebeck P & Rydberg U. (1991). Mortality in patients with
substance abuse: a follow-up in Stockholm County, 197384. International Journal of
484 References and further reading
Addiction, 89, 8517.
12. Oppenheimer E, Tobutt C, Taylor C & Andrew T (1994). Death and survival in a cohort of
heroin addicts from London clinics: a 22-year follow-up study. Addiction, 89, 1299308.
13. Ghodse H, Oyefeso A & Kilpatrick B (1998). Mortality of drug addicts in the United
Kingdom (196793). International Journal of Epidemiology, 27, 4738.
14. Caplehorn JRM, Stella M, Dalton YN, et al. (1994). Retention in methadone maintenance
and heroin addicts risk of death. Addiction, 89, 2037.
15. International Narcotics Control Board (1991). Narcotic Drugs. Estimated World Require-
ments for 1993. Statistics for 1991. Vienna: United Nations.
16. Ghodse AH, Sheehan M, Stevens, Taylor C & Edwards G (1978). Mortality among addicts
in Greater London. British Medical Journal, ii, 17424.
17. Oyefeso A, Valmana H, Clancy C, et al. (2000). Fatal antidepressant overdose among drug
abusers and non-drug abusers Acta Psychiatrica Scandinavica, 102, 2959.
18. Gossop M, Marsden J, Stewart D & Rolfe A (1999). The National Treatment Outcome
Research Study: Changes in Substance Use, Health and Crime. Fourth Bulletin. London:
Department of Health.
19. National Institute on Drug Abuse (1990). Drug Abuse Treatment Outcome Studies, Back-
ground. (http://www.datos.org/background.htmlDARP and TOPs Wndings.)
20. Marsch LA (1998). The eYcacy of methadone maintenance interventions in reducing illicit
opiate use, HIV risk behavior and criminality: a meta-analysis. Addiction, 93, 51532.
21. Hubbard, RI, Craddock G, Flynn P et al. (1997). Overview of 1-year outcomes in the Drug
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78.
22. Charney DA, Paraherakis AM & Gill KJ (2000). The treatment of sedative-hypnotic
dependence: evaluating clinical predictors of outcome. Journal of Clinical Psychiatry, 61(3),
1905.
23. Broome KM, Flynn PM & Simpson DD (1999). Psychiatric comorbidity measures as
predictors of retention in drug abuse treatment programs. Health Services Research, 334,
791806.
24. Hartnoll RL, Mitcheson MC, Battersby A, et al. (1980). Evaluation of heroin maintenance in
a controlled trial. Archives of General Psychiatry, 37, 87784.
25. Mott J (1981). Criminal involvement and penal response. In Drug Problems in Britain; a
Review of Ten Years, ed. G Edwards & C Busch. London: Academic Press.
26. Rydell CP, Caulkins JP & Everingham S (1996). Enforcement of treatment, modelling the
relative eYcacy of alternatives for controlling cocaine. Operations Research, 44, 68795.
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for cocaine addiction in DATOS. Drug and Alcohol Dependence, 57, 16774.
28. Healey A, Knapp M, Astin J et al. (1998). Economic burden of drug dependency. Social
costs incurred by drug users at intake to the National Treatment Outcome Research Study.
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29. Gerstein DR, Johnson RA, Harwood HJ, et al. (1994). Evaluating recovery services: the
California drug and alcohol treatment assessment (CALDATA). Sacramento, CA: Depart-
ment of Alcohol and Drug Programs.
485 References and further reading
Chapter 11
1. United Nations OYce for Drug Control and Crime Prevention (2000). World Drug Report
2000. Oxford: Oxford University Press.
2. OYcial Records of the United Nations Conference for the Adoption of a Convention against
Illicit TraYc in Narcotic Drugs and Psychotropic Substances, Vienna, 25 November 20
December 1988, vol. I. New York: United Nations (Sales no. E94.XI.5).
3. International Narcotics Control Board (1999). Report of the International Narcotics Control
Board 1999. New York: United Nations (Sales no. E.00.XI.1).
4. International Narcotics Control Board (2000). Report of the International Narcotics Control
Board 2000. New York: United Nations (Sales no. E.01.XI. 1).
5. Ghodse H (1999). Guiding principles of drug demand reduction: an international response.
British Journal of Psychiatry, 175, 31012.
6. Ghodse H (1995). International Policies on addiction. Strategy for development and
cooperation. British Journal of Psychiatry, 166, 1458.
7. United Nations International Drug Control Programme (1997). World Drug Report 1997.
New York: Oxford University Press.
8. International Narcotics Control Board (1997). Report of the International Narcotics Control
Board 1997. New York: United Nations.
9. Ghodse H & Khan I (1988). Psychoactive Drugs: Improving Prescribing Practices. Geneva:
WHO.
10. Falkowski J & Ghodse AH (1989). Undergraduate medical school training in psychoactive
drugs and rational prescribing in the United Kingdom. British Journal of Addictions, 84,
153942.
11. World Health Organization (1988). Ethical Criteria for Medicinal Drug Promotion. Geneva:
WHO.
12. World Health Organization (1983). The Use of Essential Drugs. Report of a WHO Expert
Committee. (Technical report series 685.) Geneva: WHO.
13. Falkowski J, Ghodse AH, Dickinson R & Khan I (1989). An international survey of the
educational activities of schools of pharmacy on psychoactive drugs. Bulletin of the World
Health Organization, 67, 5614.
14. Dorn N (1981). Social analyses of drugs in health education and the media. In Drug
Problems in Britain: A Reviewof Ten Years, ed. G Edwards & C Busch, pp. 281304. London:
Academic Press.
15. Bell CS & Battjes R (eds.) (1985). Prevention Research: Deterring Drug Abuse Among
Children and Adolescents. (NIDA research monograph 63.) Rockville, MD: Department of
Health & Human Services.
16. Boys A, Marsden J, Fountain J, GriYths P, Stillwell G & Strang J (1999). What inXuences
young peoples use of drugs? A qualitative study of decision making. Drugs: Education,
Prevention and Policy, 6, 37387.
17. National Institute on Drug Abuse (1997). Drug Abuse Prevention for At-Risk Individuals.
Rockville, MD: US National Institutes of Health.
18. Pittman DJ (1994). Substance misuse prevention, health promotion, and health education.
Current Opinion in Psychiatry, 7, 26973.
486 References and further reading
19. World Health Organization (1993). Health Promotion in the Work Place: Alcohol and Drug
Abuse. Report of a WHO Expert Committee. (Technical report series 833.) Geneva: WHO.
20. National Institute on Drug Abuse (1998). Assessing Drug Abuse Within and Across Commu-
nities. (NIH publication 983614.) Rockville, MD: Department of Health and Human
Services.
21. Room R & Paglia A (1998). Preventing Substance Use: Problems Among Youth: A Literature
Review and Recommendations. (Research document series 142.) Toronto: Addiction Re-
search Foundation.
22. Tyrer P & Murphy S (1987). The place of benzodiazepines in psychiatric practice. British
Journal of Psychiatry, 151, 71923.
23. World Health Organization (1989). WHO Expert Committee on Drug Dependence: Twenty-
Fifth Report. (Technical report series 775.) Geneva: WHO.
24. Shufman EN, Porat S, Witztum E, et al. (1994). The eYcacy of naltrexone in preventing
reabuse of heroin after detoxiWcation. Biological Psychiatry, 35, 93545.
25. Schuster CR (1992). Drug abuse research and HIV/AIDS: a national perspective from the
US. British Journal of Addiction, 87, 35561.
26. London M (2001). Prevention of substance misuse. Current Opinion in Psychiatry, 14,
20711.
Chapter 12
1. International Opium Convention 1912. League of Nations, Treaty Series, vol. VIII, p. 187.
2. Bayer I & Ghodse H (1999). Evolution of international drug control 19451995. Bulletin on
Narcotics, LI (1 and 2), 117.
3. International Opium Convention 1925. League of Nations, Treaty series, vol. LXXXI,
p. 317.
4. Convention for Limiting the Manufacture and Regulating the Distribution of Narcotic
Drugs 1931. League of Nations, Treaty series, vol CXXXIX, p. 301.
5. Convention for the Suppression of the Illicit TraYc in Dangerous Drugs 1936. League of
Nations, Treaty series, vol CXCVIII, p. 299.
6. Protocol amending the Agreements, Conventions and Protocols on Narcotic Drugs 1946.
United Nations, Treaty series, vol. 12, p. 179.
7. Protocol Bringing under International Control Drugs Outside the Scope of the Convention
of 13 July 1931 for Limiting the Manufacture and Regulating the Distribution of Narcotic
Drugs as amended by the Protocol 1946. United Nations, Treaty series, vol. 44, p. 277.
8. Protocol for Limiting and Regulating the Cultivation of the Poppy Plant, the Production of,
International and Wholesale Trade in and Use of Opium 1953. United Nations, Treaty
series, vol. 456, p. 3.
9. Single Convention on Narcotic Drugs 1961. United Nations, Treaty series, vol. 520, no.
7515.
10. Protocol amending the Single Convention on Narcotic Drugs 1961 (1972). United Nations,
Treaty series, vol. 976, no. 14152.
11. Convention on Psychotropic Substances (1971). United Nations, Treaty series, vol. 1019,
no. 14956.
487 References and further reading
12. United Nations Convention against Illicit TraYc in Narcotic Drugs and Psychotropic
Substances (1988). OYcial Records of the United Nations Conference for the Adoption of a
Convention against Illicit TraYc in Narcotic Drugs and Psychotropic Substances, Vienna,
25 November 20 December 1988, vol 1. New York: United Nations (Sales no. E.94.XI.5).
13. United Nations Commission on Narcotic Drugs (2001). 44th session. Vienna: United
Nations.
14. International Narcotics Control Board (2002). Report of the International Narcotics Con-
trol Board for 2001. New York: United Nations.
15. United Nations General Assembly (1998). Declaration of the Guiding Principles of Demand
Reduction. (A/S-20/11.) Vienna: United Nations.
16. Ghodse H (1999). Guiding principles of drug demand reduction: an international response.
British Journal of Psychiatry, 175, 31012.
17. Political Declaration and Global Programme of Action (1990). (Feb A/Res/S-17/2.) New
York: United Nations.
18. Bucknell P & Ghodse AH (1996). Misuse of Drugs, 3rd edn. London: Sweet and Maxwell.
19. United Nations OYce for Drug Control and Crime Prevention (1997). World Drug Report.
New York: Oxford University Press.
20. United Nations OYce for Drug Control and Crime Prevention (2000). World Drug Report.
Oxford: Oxford University Press.
21. Rexed B, Edmondson K, Khan I & Samson RJ (1984). Guidelines for the Control of Narcotic
and Psychotropic Substances in the Context of the International Treaties. Geneva: WHO.
22. Ghodse H (1995). International policies on addiction. Strategy developments and co-
operation. British Journal of Psychiatry, 166, 1458.
23. Cabinet OYce (2000). The United Kingdom Anti-Drug Co-ordinators Second National Plan.
London: Cabinet OYce.
488 References and further reading
Index
Numbers in italics indicate tables or Wgures .
A & E see accident and emergency (A & E)
departments
AA see Alcoholics Anonymous
abdominal signs of drug abuse 176
abscesses 283
abstinence (withdrawal) syndromes 56
neonatal 31819
treatment in A & E departments 3357
see also speciWc drugs
acamprosate 158
accident and emergency (A & E) departments
data collection by 339
diagnosis of drug dependence by 338
drug-seeking attendance 335, 337
in epidemiological research 657
management of drug overdose 3378
see also unconscious patients
as routes into specialist treatment 3389
treatment of abstinence syndromes 3357
use by drug-dependent patients 335
acetaldehyde dehydrogenase (ALDH) 149
l-alpha acetylmethadol (LAAM;
levacetylmethadol) 102, 2645, 311
active listening 218
acupuncture 2502
acute intoxication 1934
ADHD (attention deWcit hyperactivity disorder)
85, 11617
adolescent drug abuse 1617
adrenalin 113
Advisory Council on Misuse of Drugs (ACMD)
399400
Afghanistan, drug problems 867, 88
Africa, drug problems 78, 79, 81
aggressive patients 2401
agonist-antagonists (opioid) 1046
AIDS
clinical features 288
public health data (UK) 68, 69
treatment 2912
see also HIV
alanine aminotransferase (ALT) 148
alcohol 14362
acute intoxication 1523, 193, 194
adverse eVects 150
fetal alcohol syndrome 1512
liver damage 1501
neurological syndromes 151
alcohol use disorders see alcohol use disorders
(AUDs)
combined use with other drugs 1412
consumption
by women 147
by young people 1467
control policies 15962
in European countries 1456
and hepatitis C 298
and psychiatric comorbidity 330
dependence syndrome 145
disorders related to (DSM-IV) 206
drink driving 15960
Wnancial costs to countries 159
harmful drinking 144
hazardous drinking 1445
licensing regulations 1612
metabolism 14950
problem drinking 145
safe limits 144
taxation 1601
units of 143, 144
alcohol dehydrogenase (ADH) 149
alcohol use disorders (AUDs)
diagnosis 1479
management
acute intoxication 1523
alcohol withdrawal 153
detoxiWcation 1536
relapse prevention
abstinence 157
brief intervention 1567
controlled drinking 157
pharmacological approaches 1578
treatment matching 159
Alcohol Use Disorders IdentiWcation Test
(AUDIT) 148
alcoholic dementia 151
Alcoholics Anonymous (AA) 2334
eVectiveness 235
489
Alcoholics Anonymous (AA) (cont.)
Twelve Steps 453
alcoholism, genetic factors 19
aldehyde dehydrogenase 19
alkaloids 95
alpha interferon 297
alternative medicine 2523
amantadine 275
-aminobutyric acid (GABA) 112
amnesic syndrome (ICD-10) 1989
amotivational syndrome 132
amphetamine sulphate 113
amphetamine-type stimulants
drugs 11517
global seizure data 76, 78, 79
related disorders (DSM-IV) 206
amphetamines
adverse eVects 115, 3045
dependence on 11415
distribution in blood and urine 185
eVects 11314
mode of action 113
prevalence of abuse 91, 92
related disorders (DSM-IV) 206
seizures of 45
tolerance 114
treatment of adverse eVects 305
amylobarbitone 185
anabolic steroids 1389
analgesics
inequality of access to 71
minor, abuse of 910, 140
see also speciWc drugs
angel dust (phencyclidine) 1267
anhedonia 19
antagonists
benzodiazepine 11213
opioid 99, 104
Anti-Drugs Coordination Unit (UKADCU)
399
antibody production for immunoassays 186
anticoagulant abuse 10
antiretroviral drugs 2912
antisocial personality disorder (ASPD) 331
antiviral drugs
for hepatitis C 297
for HIV 2912
arrest referral schemes 42
Asian drug problems
East and South-East Asia 856
South Asia 86
West Asia 868
aspartate aminotransferase (AST) 148
aspirin abuse 910
assertiveness training 222
assessment of patients 16390
applicability 189
attendance record form 462
by social workers 1701
drug history 1645, 1667
and family assessment 1723
general points 1634, 18990
laboratory investigations
for drugs see laboratory investigations for
drugs
general health status 1803
life history 165, 167, 1689
mental state examination 17780
physical examination 1737
psychological 180
Substance Abuse Assessment Questionnaire
41454
welfare of children 3213
Asthma cigarettes 141
attendance record form 462
attention deWcit hyperactivity disorder (ADHD)
85, 11617
AUDIT (Alcohol Use Disorders IdentiWcation
Test) 148
AUDs see alcohol use disorders
Australia
drug policy 36
drug problems 901
aversion therapy 226
bacterial infections in drug abusers 283, 284, 285
bacteriological investigations 183
bad trips 125, 179, 193
barbiturates
chronic intoxication 109
cross-tolerance 112
death rates from 357
derivation 110
distribution in blood and urine 185
duration of action 110
neonatal abstinence syndrome 319
tolerance 6
treatment of overdose 312, 313
withdrawal
detoxiWcation schedule 273
stabilization on phenobarbitone 270, 271
barbiton 110
behaviour therapy
aversive conditioning 226
basis in learning theories 2201
contingency management 2235
cue exposure 227
other approaches 226
see also cognitive behaviour therapy (CBT)
Benzedrine 113
benzodiazepines
consumption in diVerent countries 72
distribution in blood and urine 185
duration of action 111
equivalent doses of diazepam 269
properties 111
psychological dependence 110
receptors 11213
seizures of 46
treatment
abstinence syndrome 336
overdose 312
use in alcohol withdrawal 154
withdrawal
490 Index
detoxiWcation schedule 272
stabilization on diazepam 271
see also sedative hypnotic drugs, withdrawal
benzphetamine 115
beta-adrenoceptor blockers 247
beta-endorphin 99, 100
bhang 128
blood
drug levels and half-lives in 184, 185
tests 1802
transmission of HIV 287
blunts 84
Brain Committee 25
breast feeding 319, 3201
British system for dealing with addiction 245
buprenorphine 1056
combined with naloxone 266
equivalent dose of methadone 256
for opioid maintenance 89, 2656
prescription in instalments 396
butobarbitone 185
butorphanol 106
caVeine
dependence 8
related disorders 207
CAGE test 148
Candida spp. 284, 288
cannabis
amotivational syndrome 132
dependence 1301
distribution in blood and urine 185
eVects 129
Xashbacks 132
gateway eVect 17
global seizure data 46, 76, 77, 78
and low birthweight 318
pharmacokinetics of THC 128
preparations 1278
prevalence of use 27, 91, 92
production 75
psychosis 1312, 303
reclassiWcation (UK) 3934
related disorders (DSM-IV) 207
tolerance 130
see also speciWc countries drug problems
Cannabis sativa 127
CARATS 43
carbohydrate-deWcient transferrin (CDT) 148,
149
cardiovascular signs of drug abuse 175
Care Programme Approach (CPA), dual diagnosis
patients 332
carfentanil 138
Caribbean drug problems 83
casual drug use 2
casualty see accident and emergency (A & E)
departments
Catha edulis (khat) 1223
cathine 122
cathinone 122, 123
CBT see cognitive behaviour therapy (CBT)
CD4 T-lymphocytes, infection by HIV 285, 286,
288
CDTs (Community Drug Teams) 40
cellulitis 283
Central American drug problems 83
charas 128
chasing the dragon 30, 101
chest radiography 183
Child Assessment Order 324
Child Protection Register 325
children at risk
abuse/neglect 321
assessment procedure 3213
case conferences 325
long term eVects of drug exposure in utero
321
management plan formulation 3234
removal from home 3245
see also neonates of drug abusers
China white 136
chlordiazepoxide 1534, 269
chlormethiazole see clomethiazole
chlorpromazine 247, 303, 305, 319
chromatography 186
cirrhosis 1501, 294, 296
classiWcation of controlled drugs (UK)
classes 393
schedules 3945
classiWcation of substance-use disorders
190210
DSM-III-R 2002
DSM-IV see DSM-IV
ICD-10 see ICD-10
systems 1901
clomethiazole
in alcohol detoxiWcation 154, 155
distribution in blood and urine 185
in opioid detoxiWcation 250, 251
clonidine, in opioid detoxiWcation 2478, 249,
250
CND (Commission on Narcotic Drugs) 3889
cocaine 117
adverse eVects 1212, 3045
distribution in blood and urine 185
eVects 11819
global production 73, 75
illicit manufacture 401
and low birthweight 318
mechanism of action 121
numbers of addicts (UK) 54, 55, 56, 57
physical dependence 11920
prescription to addicts 3967
prevalence of abuse 91, 93
psychological dependence 1201
related disorders (DSM-IV) 207
routes of administration 11718
seizures of (UK) 44, 45
tolerance 119
treatment of dependence 2756
use with alcohol 141, 142
vaccine 276
see also speciWc countries drug problems
491 Index
codeine 103
distribution in blood and urine 185
equivalent dose of methadone 256
global consumption 71
in opioid detoxiWcation 255
coerced treatment 238
coVee, brief history xiiixiv
cognitive behaviour therapy (CBT) 2212
contingency management 2235
relapse prevention 222
skills training 2223
cognitive state and drug abuse 180
cognitive therapy 220, 221
Commission on Narcotic Drugs (CND) 3889
Community Drug Teams (CDTs) 40
Community Reinforcement Approach 219
comorbidity see psychiatric comorbidity
compulsory treatment 238
concept houses 22930
congenital abnormalities 31718
contingency management 2235
contracts with patients 224, 259
Convention against Illicit TraYc in Narcotic
Drugs and Psychotropic Substances (1988)
384, 386
Convention on Psychotropic Substances (1971)
384, 386
convulsions 274, 314
counselling
HIV test 28891
see also drug counselling
Counselling, Assessment, Referral, Advice and
Throughcare Service (CARATS) 43
covert aversion therapy 226
crack cocaine 45, 118
craving drugs 4
crisis intervention 237
cross-tolerance 7
cue exposure 227
cutaneous signs of drug abuse 1745
Dangerous Drugs Act 1967 25
date rape drug 112
DAWN (Drug Abuse Warning Network) survey
66
DDTUs (Drug Dependence Treatment Units)
3840
deaths see mortality in drug abusers
Declaration on the Guiding Principles of Demand
Reduction (1998) 387
Defence of the Realm Regulations (1916) 234
delirium tremens 153, 155, 197
delta virus ( virus) 2967
delusions 179
dementia, alcoholic 151
Demerol see pethidine
denial 219
dependence see drug dependence
designer drugs 1358
desipramine 2756
dextromoramide 103, 256
dextropropoxyphene 103, 256
Diagnostic and Statistical Manual of Mental
Disorders see DSM-III-R; DSM-IV
diamorphine see heroin
diazepam
in alcohol detoxiWcation 154
in benzodiazepine detoxiWcation 2689, 272,
274
for convulsions 314
distribution in blood and urine 185
duration of action 111
equivalent doses of other benzodiazepines
269
in opioid detoxiWcation 250, 251
stabilization of benzodiazepine-dependent
patients on 271
diazoxide 313
dichloralphenazone 110
Diconal 103
dihydrocodeine
equivalent dose of methadone 256
global consumption 71
in opioid detoxiWcation 255
dimethoxyamphetamine (DMA)
126
dimethoxymethylamphetamine (DOM) 126
dimethyltryptamine (DMT) 126
diphenoxylate 247
dipipanone 103
controls on prescription 30, 3967
equivalent dose of methadone 256
numbers of addicts 54
disorder (use of term) 191
Distalgesic 103
disulWram 1578
DMA (dimethoxyamphetamine) 126
DMT (dimethyltryptamine) 126
doctors and the availability of prescription drugs
3703
doctors as drug abusers
confrontation by colleagues 327
diVerences from street addicts 3256
diYculty of identiWcation 326
referral to the GMC 328
responsibilities of colleagues 3267
treatment and rehabilitation 3278
Doloxene (dextropropoxyphene) 103, 256
DOM (dimethoxymethylamphetamine) 126
drink driving 15960
driving licence regulations 3467
drug abuse
complications
convulsions 274, 314
infections see infective complications of
injection
psychiatric see psychiatric complications of
drug abuse
pulmonary 299300
unconsciousness see unconscious patients
deWned 3
prevention see prevention of drug abuse
reasons for initiation/continuation 1618
see also substance abuse criteria
492 Index
Drug Abuse Reporting Programme (DARP)
35960
Drug Abuse Treatment Outcome Studies
(DATOS) 360
Drug Abuse Warning Network (DAWN) survey
66
drug abusers
assessment see assessment of patients
children of see children at risk; neonates of
drug abusers
doctors as see doctors as drug abusers
driving licences 3467
foreign travel 3478
global numbers of 91
motivation for change 21112
specimen-taking from 182
suicide rates 63
treatment services for see treatment services in
the UK
drug control (international)
current
Declaration on the Guiding Principles of
Demand Reduction 387
United Nations Conventions 3847
history
chronology 382
Hague Convention 381
League of Nations 381, 383
Shanghai Conference 381
United Nations 3834
United Nations organizations
Commission on Narcotic Drugs 3889
International Narcotics Control Board
38990
others 392
UNDCP 390
World Health Organization 3902
drug control (UK)
Advisory Council on Misuse of Drugs
399400
Anti-Drugs Coordinator 399
Drug TraYcking Act 1994 3989
Health and Safety at Work Act 1974 398
Intoxicating Substances Supply Act 1985 398
Medicines Act 1968 398
Misuse of Drugs Act 1971 3934
Misuse of Drugs Regulations
classiWcation of controlled drugs 3945
obligation to notify 397
prescriptions see prescription of controlled
drugs
National Treatment Agency 399
see also history of UK drug policy
drug counselling 21819
see also motivational interviewing
drug dependence
causes 1011
drug-related factors 1114
individual factors 1419
society 1922
deWnitions 3, 4
DSM-III-R criteria 2012
DSM-IV criteria 2034
ICD-10 criteria 1946
natural history
longitudinal studies 3534
relapse and remission 3523
see also mortality in drug abusers
physical
deWned 5
relationship with tolerance 78
withdrawal syndromes 56
psychological 45
types of 810
see also speciWc drugs
Drug Dependence Treatment Units (DDTUs)
3840
drug histories 1645, 1667
Drug Misuse Databases (DMDs) 579, 60, 339
drug oVender data 467
drug overdose
treatment in A & E departments 3378
see also unconscious patients
drug policy
non-UK countries 337
UK, historical review 2333
see also drug control (international); drug
control (UK)
drug seizure data (UK) 446
drug traYcking
global seizure data 76, 77, 78, 79
major routes 75
United Nations Convention against 3867
Drug TraYcking Act 1994 3989
Drug Treatment and Testing Orders (DTTOs)
43
drug-free wards 240
drug-related crime 478
drug-seeking behaviour 45, 14
drugs
attitudes to 201
in breast milk 3201
classiWcation of see classiWcation of controlled
drugs (UK)
combined use with alcohol 1412
deWnitions of 12
half-lives 184, 185
laboratory investigations for see laboratory
investigations for drugs
reinforcing properties 1214
screening programmes 188
terminology of use 23
DSM-III-R 2002
DSM-IV 20210
changes from DSM-III-R 2023
criteria for
dependence 2034
intoxication 205
substance abuse 205
substance withdrawal 205
substance related disorders, listed 20610
DTTOs (Drug Treatment and Testing Orders)
43
dual diagnosis see psychiatric comorbidity
493 Index
dynorphin 99
Ecstasy (MDMA) 1368
illicit manufacture 404
prevalence of abuse 93
seizures of 44, 46, 90
EMCDDA 6970
encounter groups 230
endocarditis 2835
endorphin 99, 100
enkephalins 99
environmental factors and drug abuse 1920
environmental impact of drug cultivation 3689
epidemiological information sources (UK)
4369
A & E departments 657
drug seizure data 446
drug-dependence services 67
drug-related crime data 478
index of addicts see Home OYce Index of
Addicts
mortality data see mortality data sources
numbers of drug oVenders 467
prescription audit 4850
public health data 679
RDMDs 579, 60
surveys 645
toxicology laboratories 67
ergotamine 10
Erythroxylum coca 117
escalation hypothesis of drug use 17
European countries
alcohol consumption 1456
overview of drugs problems 70, 8990
European Monitoring Centre on Drugs and Drug
Addiction (EMCDDA) 6970
European Substance Use Database (EuroSUD)
411
specimen form 41213
extinction 227
eyes, signs of drug abuse 174
Families Anonymous (FA) 2345
family assessment 1723
family factors in drug abuse 1617
family therapy 21617
fentanyl analogues 136, 138
fetal alcohol syndrome 1512
Xashbacks
after cannabis use 132, 303
after hallucinogen use 304
ICD-10 deWnition 199200
Xumazenil 312
Xunitrazepam 112
forensic physicians 342
Fortral see pentazocine
Freud, Sigmund 117
GABA (-aminobutyric acid) 112
gamma glutamyl transferase (GGT) 1489
ganja 128
gas-liquid chromatography (GLC) 186
gateway eVect 17
General Medical Council (GMC), referral of
professional addicts to 328
general practitioners (GPs)
assessment of patients 3401
drug seeking from 340
early recognition of dependence by 33940
management of drug-dependent patients
378, 245, 3412
General Sales List (GSL) medicines 398
genetics and drug dependence 19
Germany
drug policy 36
use of stimulants 80
Ghodse Opioid Addiction Test 177
ginseng abuse syndrome 141
global drug problems 77, 914
see also speciWc geographic regions
glutethimide 110
GMC see General Medical Council (GMC)
GPs see general practitioners (GPs)
group psychotherapy 21416, 230
haemoglobin 180
Hague Convention (1912) 381
hair analysis 186
half-lives of drugs 184, 185
hallucinations 179
hallucinogenic drugs 1237
LSD see lysergic acid diethylamide (LSD)
other drugs 126
psychiatric complications 3034
related disorders (DSM-IV) 2078
haloperidol 247, 305, 306
harm reduction
goals 277
instruction in solvent sniYng 279
issues regarding 281
needle exchange schemes 2779
outreach services 2801
shooting galleries 279
substitute prescribing 27980
harmful use of drugs 3, 194
hashish 128
Health and Safety at Work Act 1974 398
hepatitis, alcohol-induced 150
hepatitis A virus (HAV) 293
hepatitis B virus (HBV)
active/passive immunization 2989
clinical course 2934
health care workers with 299
prevention of transmission 2978
serological tests 181, 294
transmission 293
treatment of infection 297
vaccination of neonates of carriers 320
see also hepatitis delta virus
hepatitis C virus (HCV)
in breast milk 320
clinical course 296
health care workers with 299
494 Index
in injecting drug users 2956
prevalence 295
prevention of transmission 2978
serological tests 296
transmission 183, 295
treatment of infection 297
hepatitis delta virus ( virus; hepatitis D virus)
2967
hepatocellular carcinoma 294, 296
herbal remedies 1401
heroin 1012
abstinence syndrome 98
death rates 357
equivalent dose of methadone 256
global production 74
half-life 185
illicit manufacture 101, 401
longitudinal studies of addicts 3534
methods of administration 1012
neonatal abstinence syndrome 318
numbers of addicts 52, 54, 55, 56, 57
plasma concentration proWle 254
prescription of 3967
prevalence of abuse 91, 94
seizures of 44, 45
see also speciWc countries drug problems
high-performance liquid chromatography
(HPLC) 186
history of UK drug policy 2333
see also drug control (UK)
HIV
in breast milk 293, 320
clinical features 2878
health care workers with 299
importance of early diagnosis 290, 293
infection of CD4 T-lymphocytes 285, 286, 288
laboratory tests 1812, 286
needle exchange schemes and 277, 278
needle-stick injuries and 183
and neonates of drug abusers 320
pre- and post-test counselling 28891
in pregnancy 2923
prevalence in injecting drug users 287
prevention of transmission 182, 291
transmission 2867
treatment 2913
viral replication 286
Home OYce Index of Addicts 501
age and sex data 52, 53, 54
drugs of addiction 526, 57
injecting status 567
mortality data 613
numbers of addicts 512
hospital treatment
A & E departments see accident and emergency
(A & E) departments
compulsory 3078
general wards 3335
psychiatric wards 3323
specialist in-patient units 41
see also in-patient treatment
hostels 231
5-hydroxytryptamine (5HT) 125
ICD-10 191202
clinical conditions
acute intoxication 1934
amnesic syndrome 1989
dependence syndrome 1946
harmful use 194
other/unspeciWed disorders 200
psychotic disorder 1978
residual and late-onset psychotic disorder
199200
withdrawal state 1967
withdrawal state with delirium 197
coding scheme 1913
multiple drug abuse 192
ICPO (International Criminal Police
Organization; Interpol) 392
immunization see vaccination
immunoassay 186
in-patient treatment
aggressive patients 2401
drug-free wards 240
opioid stabilization 2578
organized activities 23940
reasons for admission 239
sedative withdrawal 2704
specialist units 41
stimulant withdrawal 276
see also hospital treatment
INCB (International Narcotics Control Board)
388, 38990
India, drug problems 86
infective complications of injection 28299
abscesses 283
AIDS see AIDS; HIV
cellulitis 283
endocarditis 2835
hepatitis 2939
septicaemia 285
inhalant-related disorders (DSM-IV) 208
interferon 297
International ClassiWcation of Diseases (WHO)
see ICD-10
International Criminal Police Organization
(ICPO; Interpol) 392
international drug control see drug control
(international)
international drug information
assessment of national requirements 72
diversion to illicit markets 72, 73
EMCDDA 6970
global production of illicit drugs 735
international audit 70
licit opioid supply and demand 702
International Narcotics Control Board (INCB)
388, 38990
Interpol (International Criminal Police
Organization; ICPO) 392
interview skills, acquisition by patients 228
intimate searches 344
Intoxicating Substances Supply Act 1985 398
495 Index
intoxication (DSM-IV criteria) 205
intravenous injection, cutaneous signs 1745
job-related skills training 2278
Kaposis sarcoma 288
khat 1223
Kompot 89
KorsakoVs psychosis 151, 199
LAAM (l-alpha acetylmethadol;
levacetylmethadol) 102, 2645, 311
laboratory investigations for drugs
choice of body Xuid 1845
hair analysis 186
interpretation of results 1878
limitations 1834
methods 1867
League of Nations 381, 383
learning theories 2201
levacetylmethadol (l- acetylmethadol; LAAM)
102, 2645, 311
licensing regulations, alcohol 1612
life histories 165, 167, 1689
lighter fuel deaths 135
liquid cannabis 128
liquid heroin 89
liver damage, alcohol-induced 1501
liver function tests 1489, 181
lofentanil 138
lofexidine 248
loperamide 247
loprazolam 269
lorazepam 111, 269, 274
lormetazepam 269
low birthweight 318
lymphatic system, signs of drug abuse 176
lysergic acid diethylamide (LSD)
adverse eVects 1256, 304
dependence 125
distribution in blood and urine 185
illicit manufacture 403
mechanism of action 124
physical eVects 1234
psychological eVects 1245
seizures of 46
tolerance 125
treatment of adverse eVects 304
lysergic acid monoethylamide 126
Mandrax 111
marijuana 128
see also cannabis
mass spectrometry 186
materno-fetal transmission see vertical
transmission
MDA (methylenedioxyamphetamine) 126, 404
MDMA (3, 4, methylene-
dioxymethamphetamine) see Ecstasy
(MDMA)
mean cell volume (MCV) screening for AUD
148, 149
Medicines Act 1968 398
Mental Health Act 1983 308
mental state examination of drug users 17780
meperidine see pethidine
meprobamate 110
mescalin 126
methadone 102
death rates 357
distribution in blood and urine 185
GP prescriptions 341
neonatal abstinence syndrome 319
numbers of addicts 54, 55, 56, 57
opioid equivalents 256
opioid maintenance 263, 264
opioid stabilization see opioids, stabilization on
seizures of 46
treatment of overdose 311
methamphetamine, illicit manufacture 402
methaqualone 78, 79, 111
methoxymethylenedioxyamphetamine (MMDA)
126
methylamphetamine 115, 185
3,4, methylene-dioxymethamphetamine (MDMA)
see Ecstasy (MDMA)
methylenedioxyamphetamine (MDA) 126, 404
methylphenidate 85, 11617
methylphenobarbitone 110
Minnesota method 2367
see also Narcotics Anonymous (NA)
miosis and opioids 96
Misuse of Drugs Act 1971 3934
Misuse of Drugs Regulations see drug control
(UK): Misuse of Drugs Regulations
MMDA (methoxymethylenedioxyamphetamine)
126
mood and drug abuse 179
morphine 101
distribution in blood and urine 185
equivalent dose of methadone 256
global consumption 71
inequality of access to 71
opioid receptor aYnities 1001
mortality data sources
cause of death statistics 59, 60
coroners courts records 60
database for misuse of volatile solvents 63
Home OYce Index 613
National Statistics 63
np-SAD 634, 4556
mortality in drug abusers
cause of death 3578
death rates 3547
motivation for change 21112
motivational interviewing 1567, 21920
mouth, signs of drug abuse 174
Munchausens syndrome 337
nalbuphine 106
naloxone
combined with buprenorphine 266
eye drops 177
in opioid detoxiWcation 249
496 Index
opioid receptor aYnities 104
in prevention of opioid abuse 378
test for opioid dependence 1767, 266
treatment of opioid overdose 31112
naltrexone
in alcohol relapse prevention 158
in opioid detoxiWcation 24950
in opioid relapse prevention 2668
narcolepsy 114
Narcotics Anonymous (NA) 2334
Twelve Steps 452
Twelve Traditions 4523
see also Minnesota method
National Programme for Substance Abuse Deaths
(np-SAD) 634, 4501
National Statistics for England and Wales,
mortality data 63
National Treatment Agency (UK) 399
National Treatment Outcome Research Study
(NTORS) 359
natural history of drug dependence see drug
dependence: natural history
natural remedies 1401
near patient testing 187
needle exchange schemes 2779
needle-freaks 262
needle-stick injuries 1823, 295
neonates of drug abusers
breast feeding 319, 3201
congenital abnormalities 31718
hepatitis B 320
HIV 320
low birthweight 318
neonatal abstinence syndrome 31819
Netherlands, drug policy 334
network therapy 217
neuroelectric treatment (NET) 252
neuroleptic drugs in opioid withdrawal 247
neuromuscular signs of drug abuse 176
nicotine-related disorders (DSM-IV) 208
nitrazepam 269
non-A, non-B (NANB) hepatitis 295
North America
drug problems 835
see also USA
nose, signs of drug abuse 174
notiWcation of drug related death, reporting
form 4501
np-SAD (National Programme for Substance
Abuse Deaths) 634, 4556
NTORS (National Treatment Outcome Research
Study) 359
Nubain 106
nurses, roles in DDTUs 389
Oceania, drug problems 901
ocular signs of drug abuse 174
omnopon 101
operant conditioning 223
opiates
term 95
see also opioids
opioids 95106, 24268
abstinence syndrome
and endogenous opioids 100
neonatal 31819
symptoms and signs 97, 98
treatment in A & E departments 3367
agonist-antagonists 1046
analgesia in dependent patients 334
antagonists 1034, 2668
drugs 1006
eVects 956
endogenous 99100
equivalent doses of methadone 256
global production and consumption (licit)
702
longitudinal studies of addicts 3534
physical dependence 967
naloxone test 1767, 266
and pregnancy 31516, 317, 318
prevalence of abuse 91, 94
psychological dependence 98
receptors 98100
related disorders (DSM-IV) 2089
term 95
tolerance 6, 96
treatment of overdose 31112
withdrawal assessment forms 45961
see also treatment outcome
opioids, detoxiWcation
accelerated 24950
acupuncture 2502
alternative medicine 2523
choice of programme 2423
fear of abstinence syndrome 244
management in primary care 245
neuroelectric treatment 252
patients attitudes 2434
relapse prevention 2668
relapses 244
using nonopioid drugs
general principles 246
indications 2456
treatment regimes 24751
using opioid drugs
choice of drug 2535
dose of methadone 2556
dose reduction regimes 2589
Wxed-term treatment contracts 259
without medical supervision 2445
opioids, maintenance treatment
heroin or methadone 263
high-dose methadone 264
LAAM 2645
oral or intravenous 2623
practical problems 262
supervised consumption 260
vs. withdrawal 2601
see also prescription of controlled drugs: to
addicts
opioids, stabilization on
choice of drug 2535
day-patient 258
497 Index
opoids, stabilization on (cont.)
in-patient 2578
LAAM 265
methadone dose 2556, 257, 258
out-patient 2567
opium
alkaloids 95
global production (illicit) 73, 74
history of use (UK) 23
poppy cultivation 85, 87
poppy straw 89
preparation of 95
oral signs of drug abuse 174
outcome of treatment see treatment outcome
outreach services 2801
over the counter medicines 140
overdose
treatment in A & E departments 3378
see also unconscious patients
oxazepam 111, 269
oxycodone 71
Pabrinex 156
Pakistan, drug policy 367
PalWum (dextromoramide) 103, 256
Pamergan see pethidine
Papaver somniferum 95
papaveretum 101
paranoid delusions 179
parents of drug abusers 172
partners of drug abusers 1723
patient assessment see assessment of patients
PCP see phencyclidine
peer pressure 16, 21
pemoline 117
pentazocine
abuse 105
combined with naloxone 378
equivalent dose of methadone 256
interactions with receptors 1045
personality disorder and drug abuse 1415, 331
pethidine 102
analogues 136, 138
equivalent dose of methadone 256
Pethilorfan see pethidine
Pharmacy Only medicines 398
phencyclidine (PCP)
adverse eVects 305
eVects 1267
management of acute intoxication 3056
related disorders (DSM-IV) 209
treatment of overdose 313
phenobarbitone
in barbiturate withdrawal 273
distribution in blood and urine 185
stabilization on 271
treatment of overdose 31213
phenothiazines 247
physeptone see methadone
physical examination of drug users 1737
police custody
arrest referral schemes 42
assessment of detainees 343
clinical safety of detainees 342
discharge from hospital 344
drug prescription and administration 3434
false confessions 345
Wtness for interview 3445
intimate searches 344
rights of detainees 3423
urine tests on detainees 48
young people in 345
polydrug abuse 289
polysubstance-related disorders (DSM-IV) 210
positive reinforcement see reinforcement
pregnancy in drug abusers
antenatal screening 317
fetal alcohol syndrome 1512
HIV infection 292
late diagnosis 315
naloxone test 177
pain relief in labour 317
risks to the fetus 31516
withdrawal from drugs 316
see also neonates of drug abusers
prescription audit 4850
prescription of controlled drugs
forms 396
legal requirements 3945
to addicts 3957
prescription drugs
availability 3703
history of abuse 279
prevention of drug abuse 36680
deWnitions 3667
importance to society 366
pharmacological approaches 3778
reduction of availability 367
illicit drugs 3689
prescription drugs 3703
reduction of demand 3734
community involvement 3767
encouragement of healthy lifestyles 374
proper use of medicines 3745
role of the media 377
speciWc target groups 3756
primary care of drug-dependent patients 378,
33942
prisons, treatment and rehabilitation in 43, 238
professional addicts see doctors as drug abusers
propranolol 247
psilocin/psilocybin 126
psychedelic drugs 1237
psychiatric comorbidity
admission to hospital 3323
aetiology 331
classiWcation 329
complexity of 3289
homotypic/heterotypic 330
management 3312
prevalence 32930
psychiatric complications of drug abuse
assessment of patients 301
causes 300
498 Index
compulsory treatment 3078
diVerential diagnosis and treatment
cannabis 303
hallucinogens 3034
phencyclidine 3056
sedatives 3067
solvents 307
stimulants 3045
drug treatment 3023
management of patients 302
psychoactive drugs
attitudes to 201
consumption in diVerent countries 72
deWned 2
diversion to illicit markets 72, 73
see also speciWc drugs
psychoactive substance use disorders (DSM-III-R)
2012
psychoanalytic theories of drug dependence
1516
psychodynamic tolerance 7
psychological assessment 180
psychologists, roles in DDTUs 39
psychoses
amphetamine 115, 3045
cannabis 1312, 303
cocaine 121, 3045
khat 123
KorsakoVs psychosis 151
and LSD 1256
psychotherapy
family 21617
group 21416
interpersonal 214
suitability for drug-dependent patients 213
support-expressive 214
therapeutic relationships 21314, 21617
psychotic disorders (ICD-10) 1978, 199200
Psychotropic Convention (1971) 384, 386
psychotropic drugs see psychoactive drugs
pulmonary complications of drug abuse
299300
pupil constriction and opioids 96
purgative abuse 10
RDMDs (Regional Drug Misuse Databases)
579, 60, 339
rebound anxiety/insomnia in benzodiazepine
withdrawal 108
receptors
benzodiazepine 11213
cannabinoid 129
cocaine 121
opioid 98100
recreational drug use 2
Regional Drug Misuse Databases (RDMDs)
579, 60, 339
rehabilitation services (UK) 412
reinforcement
by dependence-producing drugs 1214
in contingency management 2234, 225
secondary 1718
relapse prevention
AUDs see alcohol use disorders (AUDs): relapse
prevention
CBT in 222
group psychotherapy 215
see also self-help groups
relaxation training 226
religious communities 229
respiratory signs of drug abuse 176
reverse tolerance 114, 130
ribavirin 297
Rogerian counselling 218
Rohypnol 112
Rolleston Committee 24
SAAQ (Substance Abuse Assessment
Questionnaire) 41454
salicylism 10
Samurai approach 222
screening programmes for drugs 188
sections of the Mental Health Act 1983 308
sedative hypnotic drugs
abstinence syndrome 1089, 307
chronic intoxication 109, 3067
cross-tolerance 112
drugs 11012
eVects 107
groups 106
physical dependence 1078
psychological dependence 10910
tolerance 107
treatment of overdose 31213
sedative hypnotic drugs, withdrawal
convulsions during/after 274
in-patient detoxiWcation
detoxiWcation schedules 2723
observation 270
postwithdrawal observation 2734
stabilization 2702
intoxication during 2745
nontherapeutic dependence 269
therapeutic dependence 2689
sedative-, hypnotic-, or anxiolytic-related
disorders (DSM-IV) 20910
seizures, alcohol withdrawal 155
self-help groups (SHGs) 2325
see also supportive groups
sensitization to amphetamine 114
septicaemia 285
serenity, tranquillity and peace (STP) 126
serotonin 125
sexual transmission of HIV 287
Shanghai Conference (1909) 381
shooting galleries 36, 279
Single Convention on Narcotic Drugs (1961)
385
skills training 2223
job-related 2278
skin, signs of drug abuse 1745
social workers
assessment of patients 1701
roles in DDTUs 39
499 Index
society and drug abuse 1922, 3612
sociological theories of addiction 20
solvent abuse see volatile solvents
South America, drug problems 813
South-West Thames Substance Use Database 58
Spain, use of stimulants 79
specimen collection from drug abusers 182
Standing Conference on Drug Abuse (SCODA)
42
Staphylococcal endocarditis 284
steroids 1389
stimulant drugs 11323, 3045
STP (serenity, tranquillity and peace) 126
Substance Abuse Assessment Questionnaire
(SAAQ) 41454
substance abuse criteria
DSM-III-R 202
DSM-IV 205
Substance Abuse Monitoring (S.A.M.)
Collaborative Project
aim of the project 408
specimen form 4067
guidelines on completion 4089
Subutex see buprenorphine
suicide 63
supportive groups 2356
surveys, epidemiological 645
Sweden, drug policy 36
Switzerland, drug policy 356
syphilis 181
Tackling Drugs strategies (UK) 32
taxes on alcohol 1601
temazepam 269
Temgesic see buprenorphine
teratogenicity and drugs of abuse 31718
-9-tetrahydrocannabinol (THC)
content in cannabis preparations 127, 128
eVects 129
pharmacokinetics 128
see also cannabis
therapeutic communities 2289
concept houses 22930
eVectiveness 231
religious 229
selection of patients 2301
thiamine supplementation 1556
thin-layer chromatography (TLC) 186
thought content and drug abuse 179
tobacco
and cannabis 17
use and mental health 330
tolerance
deWnitions 6, 204
development and maintenance 67
mechanisms of 7
psychodynamic 7
relationship with physical dependence 78
see also speciWc drugs
travel with controlled drugs 3478
treatment
compulsory 238
costbeneWt analysis 363
deWned 350
general interventions 21141
harm reduction see harm reduction
hospital see hospital treatment; in-patient
treatment
matching 241, 3601
objectives 350
retention in 361
and society 3612
see also speciWc drugs
treatment outcome 34950
achievement of abstinence 362, 363, 364
assessment time scales 3501
deWning outcome 350
diYculties of assessment 351
evaluation studies 35961
importance of early intervention 354
mortality see mortality in drug abusers
prediction 360
unknown addicts 3634
see also drug dependence: natural history
Treatment Outcome Prospective Study (TOPS)
360
treatment services (UK)
arrest referral schemes 42
community drug teams (CDTs) 40
DDTUs 3840
in-patient units 41
primary health care 378, 33942
prison medical service 43
rehabilitation facilities 412
voluntary services 42
see also hospital treatment
triazolam 269
Ts and blues 105
UK
action against designer drugs 1378
alcohol consumption 146
alcohol licensing regulations 1612
costs of alcohol misuse 159
drug control see drug control (UK)
historical review of drug policy 2333
treatment services see treatment services (UK)
use of stimulants 80
see also epidemiological information sources
(UK)
unconscious patients
Wrst-aid measures 309
other measures 31011
physical examination 30910
speciWc measures
opiate overdose 31112
phencyclidine overdose 313
sedative overdose 31213
United Nations Childrens Fund (UNICEF)
392
United Nations and drug control
Conventions 3847
organizations see drug control (international):
United Nations organizations
500 Index
Protocols 3834, 385
United Nations Educational, ScientiWc and
Cultural Organization (UNESCO) 392
United Nations International Drug Control
Programme (UNDCP) 388, 390
units of alcohol 143, 144
urea 181
urge-surWng 222
urine
acidiWcation of 305
drug excretion in 185
drug testing in 184, 185
USA
cannabis use 834
cocaine use 834
control of designer drugs 137
decriminalization of cannabis 345
drug strategy 35
other drugs of abuse 845
prohibition of alcohol 34
vaccination
cocaine 276
hepatitis B 2989, 320
Veronal 110
vertical transmission
hepatitis B virus 293
hepatitis C virus 295
HIV 287
vocational rehabilitation 2278
volatile solvents 1323
acute disturbance due to 307
dependence 135
eVects 1345, 307
methods of administration 1334
national misuse database 63
substances abused 133
tolerance 135
see also Intoxicating Substances Supply Act
1985
voluntary services 42
Wasserman reaction 181
WernickeKorsakov syndrome 151, 1556
white cell counts 180
withdrawal state
DSM-IV 205
ICD-10 1967
withdrawal syndromes see abstinence syndromes
World Health Organization (WHO), roles in drug
control 388, 3902
Youth Lifestyles Survey (1998/1999) 65
Zakami 81
zidovudine 292
501 Index